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    When we took the editorship lowest price kamagra of Evidence-Based Mental Health (EBMH) at the end of 2013, we set two main objectives. To promote and embed an evidence-based medicine lowest price kamagra (EBM) approach into daily mental health clinical practice, and to get an impact factor (IF) for EBMH. Both aims have been big challenges and we have learnt a lowest price kamagra lot.EBM has been around for about 30 years now, shaping and changing the way we practice medicine. When Guyatt and colleagues published their seminal paper in 1992,1 EBM was described as the combination of three intersecting domains. The best available evidence, the clinical lowest price kamagra state and circumstances, and patient’s preferences and values.

    EBM and EBMH have since continuously evolved to deepen our understanding of these three domains.The best available evidenceWe keep complaining about the lowest price kamagra poor quality of studies in mental health. To properly assess the effects of interventions and devices before and after regulatory approval, we all know that randomised controlled trials are the best study design.2 3 However, real-world data are crucial to shed light on key clinical questions,4 especially when adverse events5 or prognostic factors6 are investigated. It necessarily …IntroductionQuality-adjusted life years (QALYs) have been increasingly used in general medicine and in psychiatry to evaluate the impact of a disease lowest price kamagra on both the quantity and quality of life.1 One QALY is equal to 1 year in perfect health, can range down to zero (death) or may take negative values (worse than death). QALYs can be used to compare the burdens of various diseases, to appreciate the impact of their interventions, to help set priorities in resource allocations across different diseases and interventions and to inform personal decisions.The representative method to evaluate QALYs is the generic, preference-based measure of health including the Euro-Qol five dimensions (EQ-5D)2 3 and the SF-6D based on Short Form Survey-36 (SF-36).4 5 Of these, the EQ-5D is the lowest price kamagra most frequently used and is the preferred instrument by the National Institute of Health and Care Excellence in the UK. While the responsiveness of such generic measures to various mental conditions, especially severe mental illnesses, has been lowest price kamagra questioned,6 its validity and responsiveness to common mental disorders including depression and anxiety have been generally established.7 8However, the traditional focus of measurements in mental health has centred mainly on symptoms.

    Many trials have, therefore, not administered the generic health-related quality of life measures. This has hindered comparison of impacts of mental disorders vis-à-vis other medical conditions on the one hand and also evaluation of values lowest price kamagra of their interventions on the other.9 10We have been collecting individual participant-level data from randomised controlled trials of internet cognitive-behavioural therapies (iCBT) for depression,11 several of which administered both symptomatologic scales and generic health status scales simultaneously. This study, therefore, attempts to link the depression-specific measure onto the generic measure of health lowest price kamagra in order to enable estimation of QALYs for depressive states and their changes. Such cross-walking should facilitate assessment of burden of depression at its various severity and of the impacts of its various treatments.MethodsDatabaseWe have been accumulating a data set of individual participant data of randomised controlled trials of iCBT among adults with depressive symptoms, as established by specified cut-offs on self-report scales or by diagnostic interviews.11 For this study, we have selected studies that have administered the EQ-5D and depression severity scales at baseline and at end of treatment. We excluded patients if they lowest price kamagra had missing data in either of the two scales at baseline or at endpoint.

    We excluded studies that focused on patients with general lowest price kamagra medical disorders (eg, diabetes, glioma) and depressive symptoms.MeasuresEQ-5D-3LThe EQ-5D-3L comprises five dimensions of mobility, self-care, usual activities, pain/discomfort and anxiety/depression, each rated on three levels corresponding with 1=no problems, 2=some/moderate problems or 3=extreme problems/unable to do. This produces 3ˆ5=243 different health states, ranging from lowest price kamagra no problem at all in any dimension (11111) to severe problems on all dimensions (33333). Each of these 243 states is provided with a preference-based score, as determined through the time trade-off (TTO) technique in a sample of the general population. In TTO, respondents are asked to give the relative length of time in full health that they would be willing to sacrifice lowest price kamagra for the poor health states as represented by each of the 243 combinations above. The EQ-5D scores range between 1=full health and 0=death to minus values=worse lowest price kamagra than death bounded by −1.

    The scoring algorithm for the UK is based on TTO responses of a random sample (n=2997) of noninstitutionalised adults. Over the years, value lowest price kamagra sets for EQ-5D-3L have been produced for many countries/regions.2 3 7Depression severity scalesWe included any validated depression severity measures. The scale scores were converted into the most frequently used scale, namely, the Patient Health Questionnaire-9 (PHQ-9),12 using the established conversion algorithms13 14 for the Beck lowest price kamagra Depression Inventory, second edition (BDI-II)15 or the Centre for Epidemiologic Studies Depression Scale (CES-D).16The PHQ-9 consists of the nine diagnostic criteria items of major depression from the DSM-IV, each rated on a scale between 0 and 3, making the total score range 0–27. The instrument has demonstrated excellent reliability, validity and responsiveness. The cut-offs have been proposed as 0–4, 5–9, 10–14, 15–19 and 20- for no, mild, moderate, moderately severe and severe depression, respectively.12Statistical analysesWe first calculated Spearman correlation coefficients between PHQ-9 and EQ-5D total scores at baseline, at end of treatment and their lowest price kamagra changes, to establish if the linking is justified.

    Correlations were considered weak if scores were <0.3, moderate if scores were ≥0.3 and<0.7 and strong if scores were ≥0.7.17 Correlations ≥0.3 have been recommended to establish linking.18 lowest price kamagra We then applied the equipercentile linking procedure,19 which identified scores on PHQ-9 and EQ-5D or their changes with the same percentile ranks and allows for a nominal translation from PHQ-9 to EQ-5D by using their percentile values. This approach has been used successfully for scales in depression, schizophrenia or Alzheimer’s disease.14 20–22 We analysed all trials collectively rather than by trial to maximise the sample size, ensure variability in the included populations and attain robust estimates.We conducted a sensitivity analysis by excluding studies that require the conversion of various depression severity scores into PHQ-9.All the analyses were conducted in R V.4.0.2, with the package equate V.2.0.7.23Ethics statementThe authors assert that all procedures contributing to this lowest price kamagra work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Ethical approval was not required for this study as it used only deidentified patient data.FindingsIncluded studiesWe identified seven RCTs of iCBT (total n=2457), which administered validated depression scales and EQ-5D both at baseline and at endpoint (online supplemental eTable 1). Three studies included only patients with major depressive disorder (MDD), one only patients with subthreshold depression and the remaining three included both lowest price kamagra. All the studies administered EQ-5D-3L lowest price kamagra.

    PHQ-9 scores were converted from the BDI-II in three studies24–26 and from the CES-D in one study.27 The mean age of the participants was 41.8 (SD=12.3) years, 66.0% (1622/2457) were women and they scored 14.0 (5.4) on PHQ-9 and 0.74 (0.20) on EQ-5D at baseline and 9.1 (6.0) and 0.79 (0.21), respectively, at endpoint. When using the standard cut-offs of the PHQ-9,12 2.4% (60/2449) suffered from no depression (PHQ-9 scores lowest price kamagra <5), 20.2% (492/2449) from subthreshold depression (5≤PHQ-9 scores <10), 33.5% (820/2449) from mild depression (10≤PHQ-9 scores <15), 26.5% (649/2449) from moderate depression (15≤PHQ-9 scores <20) and 17.3% (424/2449) from severe depression (20≤PHQ-9 scores) at baseline.Supplemental materialEquipercentile linkingSpearman’s correlation coefficient between the PHQ-9 and the EQ-5D scores was r=−0.29 at baseline, increased to r=−0.50 after intervention and was r=−0.38 for change scores.Figure 1 shows the equipercentile linking between PHQ-9 and EQ-5D total scores at baseline and at endpoint. Figure 2 shows the same between their lowest price kamagra change scores. Table 1 summarises the correspondences between the two lowest price kamagra scales.PHQ-9 and EQ-5D total scores at baseline and endpoint. EQ-5D,Euro-Qol Five Dimensions.

    PHQ-9, PatientHealth Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 1 PHQ-9 and EQ-5D total scores at lowest price kamagra baseline and endpoint. EQ-5D,Euro-Qol Five lowest price kamagra Dimensions. PHQ-9, PatientHealth Questionnaire-9.PHQ-9 change scores and EQ-5D change scores. EQ-5D, Euro-Qol lowest price kamagra Five Dimensions. PHQ-9, Patient lowest price kamagra Health Questionnaire-9." data-icon-position data-hide-link-title="0">Figure 2 PHQ-9 change scores and EQ-5D change scores.

    EQ-5D,Euro-Qol Five lowest price kamagra Dimensions. PHQ-9, PatientHealth Questionnaire-9.View this table:Table 1 Conversion table from PHQ-9 to EQ-5D total and change scoresSensitivity analysisWhen we limited the samples to the three studies28–30 that administered PHQ-9 (total n=1375), the linking results were replicated (online supplemental eFigure 1).DiscussionThis is the first study to link a depression severity measure with the EQ-5D-3L both for total and change scores. To summarise, subthreshold depression corresponded with EQ-5D-3L index values of 0.9–0.8, mild major depression lowest price kamagra with 0.8–0.7, moderate depression with 0.7–0.5 and severe depression with 0.6–0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L index values by 0.03, and a ten-point improvement can lead to an increase by approximately 0.25.A systematic review of utility values lowest price kamagra for depression31 found that the pooled mean (SD) utilities based on studies using the standard gamble as a direct valuation method were 0.69 (0.14) for mild, 0.52 (0.28) for moderate and 0.27 (0.26) for severe major depression. The estimates based on studies using EQ-5D as an indirect valuation method were 0.56 (0.16) for mild, 0.52 (0.28) for moderate and 0.25 (0.15) for severe depression.

    One recent study regressed PHQ-9 on SF-6D scores among 394 patients in theimproving Access to Psychological Therapies (IAPT) cohort7 32 and estimated none/mild depression on PHQ-9 to be worth 0.73 lowest price kamagra SF-6D scores, moderate depression 0.65 and severe depression 0.56. Our results are largely in line with these aforementioned studies.There was a consistent difference of about 0.07 EQ-5D scores for the same PHQ-9 score if it represented the baseline or endpoint measurements (figure 1) lowest price kamagra. This is understandable because a patient would rate their health status less satisfactory if they stayed equally symptomatic as before after the treatment and also because it means that they continued to suffer from depression for longer. It is, therefore, reasonable to use the conversion table at baseline for relatively new cases of depression and that at end of treatment for more chronic cases (table 1).An effect size to be typically expected after 2 months of antidepressant pharmacotherapy33 or psychotherapy27 34 over the pill placebo condition is lowest price kamagra 0.3. Given that the average SD of PHQ-9 in the studies was about 6, an effect size of 0.3 corresponds to a difference by lowest price kamagra two points on PHQ-9.

    The differences in EQ-5D scores corresponding with the end-of-treatment PHQ-9 scores of x versus x+2, where x is between 5 and 15 (table 1), lowest price kamagra ranges between 0.08 and 0.13, producing an approximate average of 0.1 EQ-5D scores. If we assume that the same difference would continue for the ensuing 10 months, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear lowest price kamagra out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY. (See figure lowest price kamagra 3 for a schematic drawing to help understand the calculation of QALYs based on changing EQ-5D scores. In reality, the changes will be more smoothly curvilinear but the calculation will be similar.) Since one QALY is typically valuated at US$50 000 or 3000 Stirling pounds,35 such therapies would be cost-effective if they cost US$2500 to US$4500 (150 to 270 pounds) or less.

    If a 1 day fill of generic selective serotonergic reuptake inhibitor antidepressants costs 1–3 dollars and a 1-year prescription costs US$400–1200 dollars, or if 8–16 sessions of psychotherapy lowest price kamagra cost US$1600–3200 dollars, both therapies would be deemed largely cost-effective. An individual’s decision, by contrast, will and should be more variable and no one can categorically reject nor require such treatments for all patients.A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies lowest price kamagra. A patient may start with PHQ-9 lowest price kamagra of 20, corresponding with EQ-5D index value of 0.5. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if on placebo (dashed line). If we assume that the same difference would continue for the ensuing lowest price kamagra 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY.

    If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements to be expected in the control group, the gain in QALY per year would be equal to lowest price kamagra 0.05 QALY. Please note that this is a schematic drawing for illustrative purposes. In reality, the changes will be more smoothly curvilinear but lowest price kamagra the calculation will be similar. EQ-5D, Euro-Qol lowest price kamagra Five Dimensions. PHQ-9, Patient lowest price kamagra Health Questionnaire-9.

    QALY, quality-adjusted life years." data-icon-position data-hide-link-title="0">Figure 3 A schematic graph showing gains in QALY due to typical pharmacotherapies or psychotherapies. A patient may start with PHQ-9 of 20, corresponding with EQ-5D index value of 0.5 lowest price kamagra. Then they may improve after 2 months of antidepressant therapy to EQ-5D score of 0.9 (solid line), while they may improve to EQ-5D score of 0.8 even if lowest price kamagra on placebo (dashed line). If we assume that the same difference would continue for the ensuing 10 months while showing slow gradual improvement in both cases, the gain in QALY per year would be equal to 0.09 QALY. If we assume that the difference would eventually wear out over the course of the year due to naturalistic improvements lowest price kamagra to be expected in the control group, the gain in QALY per year would be equal to 0.05 QALY.

    Please note that this is a schematic drawing for lowest price kamagra illustrative purposes. In reality, the changes will be more smoothly curvilinear but the calculation will be similar. EQ-5D,Euro-Qol Five Dimensions lowest price kamagra. PHQ-9, PatientHealth lowest price kamagra Questionnaire-9. QALY, quality-adjustedlife years.Several caveats should be considered when interpreting the lowest price kamagra results.

    First, our sample was limited to participants of trials of iCBT. It may be argued that the results, therefore, would not apply to patients lowest price kamagra with depression undergoing other therapies or in other settings. Second, the correlations between PHQ-9 and EQ-5D were strong enough for total scores at endpoint and for change scores to justify linking but were somewhat weaker at baseline, probably due to limited variability in PHQ-9 scores at baseline because some lowest price kamagra studies required minimum depression scores. However, the overall correspondence between PHQ-9 scores and EQ-5D had the same shape between baseline and endpoint, which will increase credibility of the linking at baseline as well. Third, we were able to compare PHQ-9 lowest price kamagra to EQ-5D-3L only.

    The EQ-5D-5L, which measures health in five levels instead of three, has been developed to be more sensitive to change and to milder conditions.36 When data become available, we will need to link PHQ-9 and EQ-5D-5L lowest price kamagra to examine if we can obtain similar conversion values.Our study also has several important strengths. First, our lowest price kamagra sample included patients with subthreshold depression and major depression and from the community or workplace and the primary care. Furthermore, they encompassed mild through severe major depression in approximately equal proportions. Second, all the patients in our sample received iCBT or control interventions including lowest price kamagra care as usual. Potential side effects of different antidepressants, repetitive brain stimulation, electroconvulsive therapy and other more aggressive therapies must of course be taken into consideration when evaluating their impacts, but our estimates, arguably independent of lowest price kamagra major side effects, can better inform such considerations.

    Finaly, unlike any prior studies, we were able to link specific PHQ-9 scores and their changes scores to EQ-5D-3L index values.Conclusion and clinical implicationsIn conclusion, we constructed a conversion table linking the EQ-5D, the representative generic preference-based measure of health status, and the PHQ-9, one of the most popular depression severity rating scale, for both its total scores and change scores. The table will enable fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments which may bring various degrees lowest price kamagra of improvement at the expense of some potential side effects.Data availability statementData are available upon reasonable request. The overall database used for this lowest price kamagra IPD is restricted due to data sharing agreements with the research institutes where the studies were conducted. IPD from individual studies are available from the individual study authors.Ethics statementsPatient consent for publicationNot required..

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    A participant who had visited his father every weekend began visiting less often after his dad started wearing a fall detector around his wrist. Another participant believed her father was active kamagra uk review around the house, as evidenced by activity sensor data. She later realized the app was showing not her father’s movement, but his dog’s. The monitoring system picked up the dog’s movements in the living room and logged it as activity.

    Technology isn’t kamagra uk review a substitute for face-to-face interaction, stressed Crista Barnett Nelson, executive director of Senior Advocacy Services, a nonprofit group that helps older adults and their families in the North Bay area outside San Francisco. €œYou can’t tell if someone has soiled their briefs with a camera. You can’t tell if they’re in pain, or if they just need an interaction,” she said. In some instances, people being monitored kamagra uk review changed their habits in response to technology.

    Clara Berridge, a professor of social work at the University of Washington who studies the use of technology in elder care, interviewed a woman who stopped her usual practice of falling asleep on the recliner because the technology would falsely alert her family that something was wrong based on inactivity deemed abnormal by the system. Another senior reported rushing in the bathroom for fear an alert would go out if they took too kamagra uk review long. The technology presents another worry for those being monitored. €œA caregiver is generally going to be really concerned about safety.

    Older adults are often very concerned about safety too, but kamagra uk review they may also weigh privacy really heavily, or their sense of identity or dignity,” Berridge said. Charles Vergos, 92 and living in Las Vegas, is uncomfortable with video cameras in his house and wasn’t interested in wearing gadgets. But he liked the idea that someone would know if something went wrong while he was alone. His niece, who kamagra uk review lives in Palo Alto, California, suggested Vergos install a home sensor system so she could monitor him from afar.

    €œThe first question I asked is, does it take pictures?. € Vergos recalled. Because the sensors don’t have a video component, he kamagra uk review was fine with them. €œActually, after you have them in the house for a while, you don’t even think about it,” Vergos said.

    The sensors also have made conversations with his niece more convenient for him. She knows he likes to talk on the phone kamagra uk review while he’s in his chair in the den, so she’ll check his activity on her iPad to determine whether it’s a good time to call. People making audio and video recordings must abide by state privacy laws, which typically require the consent of the person being recorded. It’s not as clear, however, if consent is needed to kamagra uk review collect the activity data that sensors gather.

    That falls into a gray area of the law, similar to data collected through internet browsing. Then there is the problem of how to pay for it all. Medicaid, the federal-state health program for low-income people, does cover some kamagra uk review passive monitoring for home care, but it’s not clear how many states have opted to pay for such service. Some seniors also lack access to robust internet broadband, putting much of the more sophisticated technology out of reach, noted Karen Lincoln, founder of Advocates for African American Elders at the University of Southern California.

    The relief monitoring devices bring caregivers may be the most compelling reason for their use. Delaine Whitehead, who lives in Orange County, kamagra uk review California, started taking medication for anxiety about a year after her husband, Walt, was diagnosed with Alzheimer’s. Like Weathers-Jablonski, Whitehead sought technology to help, finding peace of mind in sensors installed on the toilets in her home. Her husband often flushed too many times, causing the toilets to overflow.

    Before Whitehead installed the sensors in 2019, Walt had caused $8,000 kamagra uk review worth of water damage in their bathroom. With the sensors, Whitehead received an alert on her phone when the water got too high. €œIt did ease up a lot of my stress,” she said. Sofie Kodner is a writer with the Investigative Reporting Program at kamagra uk review the University of California-Berkeley Graduate School of Journalism.

    The IRP reported this story through a grant from The SCAN Foundation. Sofie Kodner kamagra uk review. katherine_kodner@berkeley.edu, @KodSof Related Topics Contact Us Submit a Story TipIt was Saturday morning at Southbay Tattoo and Body Piercing in Carson, California, and owner Efrain Espinoza Diaz Jr. Was prepping for his first tattoo of the day — a memorial portrait of a man that his widow wanted on her forearm.

    Diaz, known as “Rock,” has been a tattoo artist for 26 years but still gets a little nervous when doing memorial tattoos, and this one kamagra uk review was particularly sensitive. Diaz was inking a portrait of Philip Martin Martinez, a fellow tattoo artist and friend who was 45 when he died of erectile dysfunction treatment in August. €œI need to concentrate,” said Diaz, 52. €œIt’s a picture kamagra uk review of my friend, my mentor.” A stencil of Philip Martin Martinez sits on Efrain Espinoza Diaz Jr.’s table.

    Anita Martinez chose the same portrait of her husband that is etched on his tomb.(Heidi de Marco / KHN) Martinez, known to his friends and clients as “Sparky,” was a tattoo artist of some renown in nearby Wilmington, in Los Angeles’ South Bay region. A tattoo had brought Sparky and Anita together. Sparky gave Anita her first tattoo — a portrait kamagra uk review of her father — in 2012, and the experience sparked a romance. Over the years of their relationship, he had covered her body with intertwining roses and a portrait of her mother.

    Now his widow, she was getting the same photograph that was etched on Sparky’s tomb inked into her arm. And this kamagra uk review would be her first tattoo that Sparky had not applied. €œIt feels a little odd, but Rock has been really good to us,” Anita Martinez said. Rock and Sparky “grew up together.” They kamagra uk review met in the 1990s, at a time when there were no Mexican-American-owned tattoo shops in their neighborhood but Sparky was gaining a reputation.

    €œIt was artists like Phil that would inspire a lot of us to take that step into the professional tattoo industry,” Rock said. Diaz tattoos the arm of his friend’s widow, Anita Martinez, at Southbay Tattoo and Body Piercing in Carson, California. Martinez lost her husband to erectile dysfunction treatment and chose to memorialize him by tattooing his portrait kamagra uk review on her forearm. (Heidi de Marco / KHN) After Sparky got sick, Anita wasn’t allowed in her husband’s hospital room, an isolating experience shared by hundreds of thousands of Americans who lost a loved one to erectile dysfunction treatment.

    They let her in only at the very end. €œI got cheated out of being with him in his kamagra uk review last moments,” said Martinez, 43. €œWhen I got there, I felt he was already gone. We never got to say goodbye.

    We never got to hug.” “I don’t even know if I’m ever going to heal,” she said, as Diaz began sketching the outlines of the portrait below her elbow, “but at least kamagra uk review I’ll get to see him every day.” The tattooed portrait of Philip Martin Martinez on Anita’s arm. She chose to get it on her forearm so she could see it every day. (Heidi de Marco / KHN) According to a 2015 Harris Poll, almost 30% of Americans have at least one tattoo, a 10% increase from 2011. At least 80% of tattoos are for commemoration, said Deborah Davidson, a professor of sociology at York University in Toronto who has been researching memorial tattoos kamagra uk review since 2009.

    €œMemorial tattoos help us speak our grief, bandage our wounds and open dialogue about death,” she said. €œThey help us integrate kamagra uk review loss into our lives to help us heal.” erectile dysfunction treatment, sadly, has provided many opportunities for such memorials. Juan Rodriguez, a tattoo artist who goes by “Monch,” preps his client’s arm for a memorial tattoo. (Heidi de Marco / KHN) Juan Rodriguez, a tattoo artist who goes by “Monch,” has been seeing twice as many clients as before the kamagra and is booked months in advance at his parlor in Pacoima, an L.A.

    Neighborhood in the kamagra uk review San Fernando Valley. Memorial tattoos, which can include names, portraits and special artwork, are common in his line of work, but there’s been an increase in requests due to the kamagra. €œOne client called me on the way to his brother’s funeral,” Rodriguez said. Rodriguez thinks memorial kamagra uk review tattoos help people process traumatic experiences.

    As he moves his needle over the arms, legs and backs of his clients, and they share stories of their loved ones, he feels he is part artist, part therapist. Healthy grievers do not resolve grief by detaching from the deceased but by creating a new relationship with them, said Jennifer R. Levin, a therapist in Pasadena, California, kamagra uk review who specializes in traumatic grief. €œTattoos can be a way of sustaining that relationship,” she said.

    It’s common for her patients in the 20-to-50 age range to get memorial tattoos, she said. €œIt’s a powerful way of acknowledging kamagra uk review life, death and legacy.” Sazalea Martinez, a kinesiology student at Antelope Valley College in Palmdale, California, holds a handwritten note from her grandmother with the phrase “I love you.” (Heidi de Marco / KHN) Martinez says she’s still mourning her grandparents’ deaths. €œIt’s hard to connect the two,” she says. €œI know they passed away from erectile dysfunction treatment, but to me it just feels like pain.” (Heidi de Marco / KHN) Sazalea Martinez, a kinesiology student at Antelope Valley College in kamagra uk review Palmdale, California, came to Rodriguez in September to memorialize her grandparents.

    Her grandfather died of erectile dysfunction treatment in February, her grandmother in April. She chose to have Rodriguez tattoo an image of azaleas with “I love you” written in her grandmother’s handwriting. The azaleas, which kamagra uk review are part of her name, represent her grandfather, she said. Sazalea decided not to get a portrait of her grandmother because the latter didn’t approve of tattoos.

    €œThe ‘I love you’ is something simple and it’s comforting to me,” she said. €œIt’s going kamagra uk review to let me heal and I know she would have understood that.” Sazalea teared up as the needle moved across her forearm, tracing her grandmother’s handwriting. €œIt’s still super fresh,” she said. €œThey basically raised me.

    They impacted who I am as a person, kamagra uk review so to have them with me will be comforting.” Efrain Espinoza Diaz Jr., known as “Rock,” says tattoos can be like therapy for people who have lost loved ones.(Heidi de Marco / KHN) This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Heidi de Marco. heidid@kff.org, @Heidi_deMarco Related Topics Contact Us Submit a Story Tip.

    Can’t see lowest price kamagra the audio get more player?. Click here to listen on Acast. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to lowest price kamagra podcasts. President Joe Biden’s “Build Back Better” social spending bill passed the House last week, but the legislation faces a new and different set of hurdles in the Senate, where it will need the support of every single Democrat, plus approval by the Senate parliamentarian.

    Meanwhile, erectile dysfunction treatment is surging again in Europe as well as in many parts of the United States, just as travel picks up for the holidays. And the Supreme Court prepares to hear oral arguments in an abortion case out of Mississippi that could lead to lowest price kamagra the weakening or overturning of Roe v. Wade — and could upend the political landscape in the U.S. This week’s panelists are Julie Rovner of KHN, Margot Sanger-Katz of The New York Times, Joanne Kenen of Politico and the Johns Hopkins School of Public Health, and Mary Agnes Carey of KHN.

    Among the takeaways from lowest price kamagra this week’s episode. There are roadblocks ahead in the Senate for the social spending plan. Some moderate Democrats may want to make changes, and parts of the bill could be challenged under tight Senate rules that require bills being passed using the budget reconciliation procedures — which prohibit filibustering — to show that the provisions have an effect on the budget.Among the health provisions that could be affected are paid family leave and the restrictions on drug price increases for plans outside of the Medicare program.As the bill passed by the House gets scrutinized, some of the smaller provisions that may not have garnered attention initially are now targets of debate and industry lobbying. Among them lowest price kamagra.

    A decision to tax vaping products, which some opponents suggest will lead users to continue to use cigarettes instead. Another is a mandate for nursing homes to have registered nurses in place 24/7, even though industry officials say they lowest price kamagra can’t recruit enough staff, which might lead some homes to close.If Congress does approve the bill, it’s good to remember that passage is not the final word. Industry and advocates will continue to lobby the administration on regulations to implement the legislation, and those who are distressed by the law could take their grievances to court.With the decision last week by the Food and Drug Administration and the Centers for Disease Control and Prevention to authorize erectile dysfunction treatment boosters for all adults, public health messaging on the shots has shifted. While officials were much more nuanced when boosters first became available, they are now pushing hard for everyone to get the extra doses.Public attitudes about erectile dysfunction treatment also appear to be shifting, perhaps a result of kamagra fatigue.

    Where once Americans looked lowest price kamagra to treatments to release them from the drudgeries of avoiding erectile dysfunction treatment, many now acknowledge the kamagra will be around for a long time and are struggling to figure out how to return to a more normal life. Also this week, Rovner interviews Mary Ziegler of the Florida State University College of Law about the Supreme Court’s upcoming oral arguments in the Mississippi abortion case. Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too. Julie Rovner lowest price kamagra.

    The Wall Street Journal’s “Telehealth Rollbacks Leave Patients Stranded, Some Doctors Say,” by Stephanie Armour and Robbie Whelan. Margot Sanger-Katz. The New lowest price kamagra York Times’ “Everything in the House Democrats’ Budget Bill,” by Alicia Parlapiano and Quoctrung Bui. Joanne Kenen.

    Politico’s “VA Stats Show Devastating erectile dysfunction treatment Toll at Vets’ Nursing Homes,” by Joanne Kenen, Darius Tahir and Allan James Vestal. Mary Agnes Carey lowest price kamagra. KHN’s “A erectile dysfunction treatment Head-Scratcher. Why Lice Lurk Despite Physical lowest price kamagra Distancing,” by Rae Ellen Bichell.

    To hear all our podcasts, click here. And subscribe to KHN’s What the Health?. on Spotify, Apple Podcasts, Stitcher, lowest price kamagra Pocket Casts or wherever you listen to podcasts. Related Topics Contact Us Submit a Story TipIn the middle of a rainy Michigan night, 88-year-old Dian Wurdock walked out the front door of her son’s home in Grand Rapids, barefoot and coatless.

    Her destination was unknown even to herself. Wurdock was several lowest price kamagra years into a dementia diagnosis that turned out to be Alzheimer’s disease. By luck, her son woke up and found her before she stepped too far down the street. As the Alzheimer’s progressed, so did her wandering and with it, her children’s anxiety.

    €œI was losing it,” said her daughter, Deb Weathers-Jablonski lowest price kamagra. €œI needed to keep her safe, especially at night.” Weathers-Jablonski installed a monitoring system with nine motion sensors around the house — in her mother’s bedroom, the hallway, kitchen, living room, dining room and bathroom and near three doors that led outside. They connected to an app on her phone, which sent activity alerts and provided a log of her mother’s movements. €œWhen I went to lowest price kamagra bed at night, I didn’t have to guess what she was doing,” Weathers-Jablonski said.

    €œI was actually able to get some sleep.” New monitoring technology is helping family caregivers manage the relentless task of looking out for older adults with cognitive decline. Setting up an lowest price kamagra extensive monitoring system can be expensive — Weathers-Jablonski’s system from People Power Co. Costs $299 for the hardware and $40 a month for use of the app. With scores of companies selling such gear, including SentryTell and Caregiver Smart Solutions, they are readily available to people who can pay out-of-pocket.

    But that’s not an option lowest price kamagra for everyone. While the technology is in line with President Joe Biden’s plan to direct billions of dollars toward helping older and disabled Americans live more independently at home, the costs of such systems aren’t always covered by private insurers and rarely by Medicare or Medicaid. Monitoring also raises ethical questions about privacy and quality of care. Still, the systems make it possible for many older people to stay in lowest price kamagra their home, which can cost them far less than institutional care.

    Living at home is what most people prefer, especially in light of the toll the erectile dysfunction treatment kamagra took on nursing homes. Technology could help fill a huge gap in home care for the elderly. Paid caregivers are in short supply to meet the needs of the aging population, which is expected to more than double in lowest price kamagra coming decades. The shortage is fueled by low pay, meager benefits and high rates of burnout.

    And for the nearly 1 in 5 U.S adults who are caregivers to a family member or friend over age 50, the gadgets have made a hard job just a little easier. Passive surveillance systems are replacing the “I’ve fallen and I can’t get lowest price kamagra up” medical alert buttons. Using artificial intelligence, the new devices can automatically detect something is wrong and make an emergency call unasked. They also can monitor pill dispensers and kitchen appliances lowest price kamagra using motion sensors, like EllieGrid and WallFlower.

    Some systems include wearable watches for fall detection, such as QMedic, or can track GPS location, like SmartSole’s shoe insoles. Others are video cameras that record. People use surveillance systems lowest price kamagra like Ring inside the home. Some caregivers may be tempted to use technology to replace care, as researchers in England found in a recent study.

    A participant who had visited his father every weekend began visiting less often after his dad started wearing a fall detector around his wrist. Another participant believed her father was active around the house, as evidenced by activity lowest price kamagra sensor data. She later realized the app was showing not her father’s movement, but his dog’s. The monitoring system picked up the dog’s movements in the living room and logged it as activity.

    Technology isn’t a substitute for face-to-face interaction, stressed Crista Barnett Nelson, executive director of Senior Advocacy Services, a nonprofit group that helps older adults and their families lowest price kamagra in the North Bay area outside San Francisco. €œYou can’t tell if someone has soiled their briefs with a camera. You can’t tell if they’re in pain, or if they just need an interaction,” she said. In some instances, people being monitored changed their habits in lowest price kamagra response to technology.

    Clara Berridge, a professor of social work at the University of Washington who studies the use of technology in elder care, interviewed a woman who stopped her usual practice of falling asleep on the recliner because the technology would falsely alert her family that something was wrong based on inactivity deemed abnormal by the system. Another senior reported rushing in the lowest price kamagra bathroom for fear an alert would go out if they took too long. The technology presents another worry for those being monitored. €œA caregiver is generally going to be really concerned about safety.

    Older adults are often very concerned about safety too, but they may also weigh privacy really heavily, or their sense of identity lowest price kamagra or dignity,” Berridge said. Charles Vergos, 92 and living in Las Vegas, is uncomfortable with video cameras in his house and wasn’t interested in wearing gadgets. But he liked the idea that someone would know if something went wrong while he was alone. His niece, who lives in Palo Alto, California, suggested Vergos install a home sensor system so she lowest price kamagra could monitor him from afar.

    €œThe first question I asked is, does it take pictures?. € Vergos recalled. Because the sensors don’t have a video lowest price kamagra component, he was fine with them. €œActually, after you have them in the house for a while, you don’t even think about it,” Vergos said.

    The sensors also have made conversations with his niece more convenient for him. She knows he likes to talk on the phone while he’s in his chair in the den, so she’ll check his activity lowest price kamagra on her iPad to determine whether it’s a good time to call. People making audio and video recordings must abide by state privacy laws, which typically require the consent of the person being recorded. It’s not as clear, however, if consent is needed to collect the activity data that lowest price kamagra sensors gather.

    That falls into a gray area of the law, similar to data collected through internet browsing. Then there is the problem of how to pay for it all. Medicaid, the lowest price kamagra federal-state health program for low-income people, does cover some passive monitoring for home care, but it’s not clear how many states have opted to pay for such service. Some seniors also lack access to robust internet broadband, putting much of the more sophisticated technology out of reach, noted Karen Lincoln, founder of Advocates for African American Elders at the University of Southern California.

    The relief monitoring devices bring caregivers may be the most compelling reason for their use. Delaine Whitehead, who lives in Orange lowest price kamagra County, California, started taking medication for anxiety about a year after her husband, Walt, was diagnosed with Alzheimer’s. Like Weathers-Jablonski, Whitehead sought technology to help, finding peace of mind in sensors installed on the toilets in her home. Her husband often flushed too many times, causing the toilets to overflow.

    Before Whitehead installed the sensors in 2019, Walt had caused $8,000 worth of lowest price kamagra water damage in their bathroom. With the sensors, Whitehead received an alert on her phone when the water got too high. €œIt did ease up a lot of my stress,” she said. Sofie Kodner is a writer with the Investigative Reporting Program at lowest price kamagra the University of California-Berkeley Graduate School of Journalism.

    The IRP reported this story through a grant from The SCAN Foundation. Sofie Kodner lowest price kamagra. katherine_kodner@berkeley.edu, @KodSof Related Topics Contact Us Submit a Story TipIt was Saturday morning at Southbay Tattoo and Body Piercing in Carson, California, and owner Efrain Espinoza Diaz Jr. Was prepping for his first tattoo of the day — a memorial portrait of a man that his widow wanted on her forearm.

    Diaz, known as lowest price kamagra “Rock,” has been a tattoo artist for 26 years but still gets a little nervous when doing memorial tattoos, and this one was particularly sensitive. Diaz was inking a portrait of Philip Martin Martinez, a fellow tattoo artist and friend who was 45 when he died of erectile dysfunction treatment in August. €œI need to concentrate,” said Diaz, 52. €œIt’s a picture of my friend, my mentor.” A stencil of Philip Martin Martinez sits on Efrain Espinoza Diaz Jr.’s lowest price kamagra table.

    Anita Martinez chose the same portrait of her husband that is etched on his tomb.(Heidi de Marco / KHN) Martinez, known to his friends and clients as “Sparky,” was a tattoo artist of some renown in nearby Wilmington, in Los Angeles’ South Bay region. A tattoo had brought Sparky and Anita together. Sparky gave Anita her first tattoo — a portrait of her father — in 2012, lowest price kamagra and the experience sparked a romance. Over the years of their relationship, he had covered her body with intertwining roses and a portrait of her mother.

    Now his widow, she was getting the same photograph that was etched on Sparky’s tomb inked into her arm. And this would be her first tattoo that Sparky had lowest price kamagra not applied. €œIt feels a little odd, but Rock has been really good to us,” Anita Martinez said. Rock and Sparky “grew up together.” They met in the 1990s, at a time when there were no Mexican-American-owned tattoo shops in their neighborhood but Sparky was gaining a reputation lowest price kamagra.

    €œIt was artists like Phil that would inspire a lot of us to take that step into the professional tattoo industry,” Rock said. Diaz tattoos the arm of his friend’s widow, Anita Martinez, at Southbay Tattoo and Body Piercing in Carson, California. Martinez lost her husband to erectile dysfunction treatment and chose to memorialize him by tattooing his portrait on her forearm lowest price kamagra. (Heidi de Marco / KHN) After Sparky got sick, Anita wasn’t allowed in her husband’s hospital room, an isolating experience shared by hundreds of thousands of Americans who lost a loved one to erectile dysfunction treatment.

    They let her in only at the very end. €œI got cheated out of being with him lowest price kamagra in his last moments,” said Martinez, 43. €œWhen I got there, I felt he was already gone. We never got to say goodbye.

    We never got to hug.” “I don’t even know if I’m lowest price kamagra ever going to heal,” she said, as Diaz began sketching the outlines of the portrait below her elbow, “but at least I’ll get to see him every day.” The tattooed portrait of Philip Martin Martinez on Anita’s arm. She chose to get it on her forearm so she could see it every day. (Heidi de Marco / KHN) According to a 2015 Harris Poll, almost 30% of Americans have at least one tattoo, a 10% increase from 2011. At least 80% of tattoos are for commemoration, said Deborah Davidson, a professor of sociology at York University in Toronto who has been researching memorial tattoos since 2009 lowest price kamagra.

    €œMemorial tattoos help us speak our grief, bandage our wounds and open dialogue about death,” she said. €œThey help us integrate loss into our lives to help us heal.” erectile dysfunction treatment, sadly, has lowest price kamagra provided many opportunities for such memorials. Juan Rodriguez, a tattoo artist who goes by “Monch,” preps his client’s arm for a memorial tattoo. (Heidi de Marco / KHN) Juan Rodriguez, a tattoo artist who goes by “Monch,” has been seeing twice as many clients as before the kamagra and is booked months in advance at his parlor in Pacoima, an L.A.

    Neighborhood in the lowest price kamagra San Fernando Valley. Memorial tattoos, which can include names, portraits and special artwork, are common in his line of work, but there’s been an increase in requests due to the kamagra. €œOne client called me on the way to his brother’s funeral,” Rodriguez said. Rodriguez thinks memorial tattoos help people lowest price kamagra process traumatic experiences.

    As he moves his needle over the arms, legs and backs of his clients, and they share stories of their loved ones, he feels he is part artist, part therapist. Healthy grievers do not resolve grief by detaching from the deceased but by creating a new relationship with them, said Jennifer R. Levin, a therapist lowest price kamagra in Pasadena, California, who specializes in traumatic grief. €œTattoos can be a way of sustaining that relationship,” she said.

    It’s common for her patients in the 20-to-50 age range to get memorial tattoos, she said. €œIt’s a powerful way of acknowledging life, death and legacy.” Sazalea lowest price kamagra Martinez, a kinesiology student at Antelope Valley College in Palmdale, California, holds a handwritten note from her grandmother with the phrase “I love you.” (Heidi de Marco / KHN) Martinez says she’s still mourning her grandparents’ deaths. €œIt’s hard to connect the two,” she says. €œI know they passed away from erectile dysfunction treatment, but to me it just feels like pain.” (Heidi lowest price kamagra de Marco / KHN) Sazalea Martinez, a kinesiology student at Antelope Valley College in Palmdale, California, came to Rodriguez in September to memorialize her grandparents.

    Her grandfather died of erectile dysfunction treatment in February, her grandmother in April. She chose to have Rodriguez tattoo an image of azaleas with “I love you” written in her grandmother’s handwriting. The azaleas, which are part of her name, represent her lowest price kamagra grandfather, she said. Sazalea decided not to get a portrait of her grandmother because the latter didn’t approve of tattoos.

    €œThe ‘I love you’ is something simple and it’s comforting to me,” she said. €œIt’s going to let me heal and I know she would have understood that.” Sazalea teared up as the lowest price kamagra needle moved across her forearm, tracing her grandmother’s handwriting. €œIt’s still super fresh,” she said. €œThey basically raised me.

    They impacted who I am as a person, so to have them with me will be comforting.” Efrain Espinoza Diaz Jr., known as “Rock,” says tattoos can be like therapy for people who have lost loved ones.(Heidi de Marco / KHN) This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. Heidi de Marco. heidid@kff.org, @Heidi_deMarco Related Topics Contact Us Submit a Story Tip.

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    Pictured left how to get kamagra in the us to right is the Radiation Oncology team, Krystina Haggerty-McNeil, Curt Hampton, Mario Lacerna, M.D., Stephanie Haggerty-McNeil, Liza Morris, Denelle Shultz, Jin Xian Dai, Roxanne Foor.The American Society for Radiation Oncology (ASTRO) recently awarded four-year accreditation to MidMichigan Medical Center – Alpena for adopting procedures to encourage safety and quality of care in compliance with Can you buy ventolin over the counter in america the standards of the Accreditation Program for Excellence (APEx®). APEx is an accreditation program developed by ASTRO that validates a radiation oncology facility’s excellence in delivering high-quality patient care.“We are very pleased to have received APEx accreditation from ASTRO, the how to get kamagra in the us largest radiation oncology society in the world.” said Mario Lacerna, M.D., medical director, radiation oncology Medical Director “Our entire radiation oncology team was invested in evaluating our processes to meet ASTRO’s high standards for safety and quality. Securing APEx accreditation serves to reinforce our obligation to deliver consistent patient-centered cancer care.”“ASTRO commends the Cancer Center for how to get kamagra in the us achieving APEx accreditation. By undergoing this comprehensive review, the facility has demonstrated a strong commitment to delivering safe, high-quality radiation oncology services to their how to get kamagra in the us patients,” said Thomas J.

    Eichler, MD, FASTRO, chair of the ASTRO Board of Directors.Accreditation through APEx is a voluntary, rigorous multi-step process during which a how to get kamagra in the us facility’s practices are evaluated using consensus-based standards. The center must demonstrate its safety and quality processes and demonstrate that it adheres to patient-centered care by promoting effective communication, coordinated treatments and strong patient engagement.The APEx accreditation process includes a facility self-assessment as well as a comprehensive onsite facility review by a radiation oncologist and a medical physicist. The program reflects the how to get kamagra in the us recommendations endorsed in the ASTRO publication Safety is No Accident. A Framework for Quality Radiation Oncology how to get kamagra in the us and Care.

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    During the Medicare open enrollment period from October 15 to December 7 each year, beneficiaries can enroll in a plan that provides Part D drug http://sjaynephotography.com/seniors7/ coverage, either a stand-alone prescription drug plan (PDP) as a ajanta pharma kamagra price supplement to traditional Medicare, or a Medicare Advantage prescription drug plan (MA-PD), which covers all Medicare benefits, including drugs. Among the 46 million Part D enrollees in 2020, 20.2 million (44%) are in PDPs and 19.3 million (41%) are in ajanta pharma kamagra price MA-PDs (excluding the 7.0 million (15%) in employer-only group PDPs and MA-PDs). This issue brief provides an overview of Medicare Part D drug plans that will be available in 2021 and key trends over time.Part D Plan AvailabilityThe Average Medicare Beneficiary Has a Choice of Nearly 60 Medicare Plans with Part D Drug Coverage in 2021, Including 30 Medicare Stand-alone Drug Plans and 27 Medicare Advantage Drug PlansFigure 1. The Average Medicare Beneficiary Has a Choice of Nearly 60 Medicare Plans Offering Drug Coverage in 2021, Including 30 ajanta pharma kamagra price Stand-alone Drug Plans and 27 Medicare Advantage Drug PlansA larger number of Part D plans will be offered in 2021 than in recent years. The average Medicare beneficiary will have a choice of 30 stand-alone PDPs in 2021, two more PDP options than in 2020, and eight more than in 2017, a 36% increase (Figure 1).

    Although the number of PDP options in 2021 is half of what it was ajanta pharma kamagra price at the peak in 2007 (when there were 56 PDP options, on average), this is the fourth year in a row with an increase in the average number of stand-alone drug plan options.In 2021, beneficiaries will also have access to 27 MA-PDs, on average, a 71% increase in MA-PD options since 2017 (excluding Medicare Advantage plans that do not offer the drug benefit and plans not available to all beneficiaries. Overall, an average of 33 Medicare Advantage plan options will be available in 2021).Based on September 2020 enrollment, 8 out of 10 PDP enrollees (80%) in 2021 are projected to be in PDPs operated by just four firms. UnitedHealth, Centene (which acquired ajanta pharma kamagra price WellCare in 2020), Humana, and CVS Health (based on PDP enrollment as of September 2020). All four firms offer PDPs in all 34 PDP regions in 2021.A Total of 996 Medicare Part D Stand-Alone Prescription Drug Plans Will Be Offered in 2021, a 5% Increase From 2020 and a 34% Increase Since 2017 Figure 2. A Total of 996 Medicare Part D Stand-Alone Prescription Drug Plans Will Be Offered in 2021, a 5% Increase From 2020 and a 34% Increase Since ajanta pharma kamagra price 2017​A total of 996 PDPs will be offered in the 34 PDP regions in 2021 (plus another 11 PDPs in the territories), an increase of 48 PDPs (5%) over 2020, and 250 more PDPs (a 34% increase) since 2017 (Figure 2).

    This increase is primarily due to the Trump Administration’s elimination of the “meaningful difference” requirement for enhanced benefit PDPs offered by the same organization in the same region. Eliminating this requirement means that PDP sponsors no longer ajanta pharma kamagra price have to demonstrate that their enhanced PDPs offered in the same region are meaningfully different in terms of enrollee out-of-pocket costs. In 2021, 62% of PDPs (618 plans) will offer enhanced Part D benefits—a 60% increase in the availability of enhanced-benefit PDPs since 2017, when just over half of PDPs (387 plans) offered enhanced benefits.The number of PDPs per region in 2021 will range from 25 PDPs in Alaska to 35 PDPs in Texas and will be the same or higher in 32 of the 34 PDP regions compared to 2020 (see map, Table 1). Part D PremiumsThe Estimated Average ajanta pharma kamagra price Monthly Premium for Medicare PDPs Is Projected to Increase by 9% to $41 in 2021, Based on Current EnrollmentFigure 3. The Estimated Average Monthly Premium for Medicare PDPs Is Projected to Increase by 9% to $41 in 2021, Based on Current Enrollment​The estimated national average monthly PDP premium for 2021 is projected to increase by 9% to $41, from $38 in 2021, weighted by September 2020 enrollment (Figure 3).

    It is likely that the actual average weighted premium for 2021, after taking into ajanta pharma kamagra price account enrollment choices by new enrollees and plan changes by current enrollees, will be somewhat lower than the estimated average. CMS reported that the average premium for basic Part D coverage offered by PDPs and MA-PDs will be an estimated $30 in 2021. Our premium estimate is higher because it is based on PDPs only (excluding MA-PDs) and includes PDPs offering both basic and enhanced coverage (enhanced plans, which account for 62% of all PDPs in 2021, have higher premiums than basic plans, on average).Average Monthly Premiums ajanta pharma kamagra price for the 21 National Part D Stand-alone PDPs Are Projected to Range from $7 to $89 in 2021, with Higher Average Premiums for Enhanced Benefits and Zero-Deductible PDPsFigure 4. Average Monthly Premiums for the 21 National Part D Stand-alone Drug Plans Are Projected to Range from $7 to $89 in 2021​PDP premiums will vary widely across plans in 2021, as in previous years (Figure 4, Table 2). Among the 21 PDPs available nationwide, average premiums will range from a low of $7 per month for SilverScript ajanta pharma kamagra price SmartRx to a high of $89 per month for AARP MedicareRx Preferred.Changes to premiums from 2020 to 2021, averaged across regions and weighted by 2020 enrollment, also vary widely across PDPs, as do the absolute amounts of monthly premiums for 2021.The 1.9 million non-LIS enrollees in the largest PDP, CVS Health’s SilverScript Choice (which had a total of 3.9 million enrollees in 2020, including those receiving low-income subsidies) will face a modest $1 (2%) decrease in their average monthly premium, from $29 in 2020 to $28 in 2021.In contrast, the 1.8 million non-LIS enrollees in the second largest PDP, AARP MedicareRx Preferred, will face a $10 (12%) increase in their average monthly premium between 2020 and 2021, from $79 to $89.

    This is the highest monthly premium among the national PDPs in 2021.The 1.3 million non-LIS enrollees in ajanta pharma kamagra price the fourth largest PDP, Humana Premier Rx, will see a $7 (13%) increase in their monthly premium, from $58 in 2020 to $65 in 2021.Most Part D stand-alone drug plans in 2021 (62% of PDPs) will offer enhanced benefits for a higher monthly premium. Enhanced benefits can include a lower (or no) deductible, reduced cost sharing, or a higher initial coverage limit than under the standard benefit design. The average premium in 2021 for enhanced benefit PDPs ajanta pharma kamagra price is $51, which is 55% higher than the monthly premium for PDPs offering the basic benefit ($33) (weighted by September 2020 enrollment).In 2021, a large majority of PDPs (86%) will charge a deductible, with most PDPs (67%) charging the standard amount of $445 in 2021. Across all PDPs, the average deductible in 2021 will be $345 (weighted by September 2020 enrollment). The average monthly premium in ajanta pharma kamagra price 2021 for PDPs that charge no deductible is $88, nearly three times the monthly premium for PDPs that charge the standard deductible ($34) or a partial deductible ($31) (weighted by September 2020 enrollment).Nearly 8 in 10 Part D Stand-alone Drug Plan Enrollees Without Low-income Subsidies Will Pay Higher Premiums in 2021 If They Stay in Their Current PlanFigure 5.

    Nearly 8 in 10 Part D Stand-alone Drug Plan Enrollees Without Low-income Subsidies Will Pay Higher Premiums in 2021 If They Stay in Their Current Plan​Most (78%, or 10 million) of the 13.4 million Part D PDP enrollees who are responsible for paying the entire premium (which excludes Low-Income Subsidy (LIS) recipients) will see their monthly premium increase in 2021 if they stay in their same plan, while 2.8 million (21%) will see a premium reduction if they stay in their same plan (Figure 5).Nearly 2 million non-LIS enrollees (13%) will see a premium increase of $10 or more per month, while significantly fewer (0.2 million non-LIS enrollees, or 1%) will see a premium reduction of the same magnitude. One-third (34%) of non-LIS enrollees (4.6 million) are projected to pay monthly premiums of at least $60 if they stay in their current plans, and more than 230,000 (2% of non-LIS enrollees) are projected to pay monthly premiums of at least $100.The Average Monthly Part D Premium in 2021 ajanta pharma kamagra price for the Subset of Enhanced Stand-alone Drug Plans Covering Insulin at a $35 Monthly Copay Is Substantially Higher Than Premiums for Other PDPsFigure 6. The Average Monthly Part D Premium in 2021 for the Subset of Enhanced Stand-alone Drug Plans Covering Insulin at a $35 Monthly Copay is Substantially Higher than Premiums for Other Plans​New for 2021, beneficiaries in each state will have the option to enroll in a Part D plan participating in the Trump Administration’s new Innovation Center model in which enhanced drug plans cover insulin products at a monthly copayment of $35 in the deductible, initial coverage, and coverage gap phases of the Part D benefit. Participating plans do not ajanta pharma kamagra price have to cover all insulin products at the $35 monthly copayment amount, just one of each dosage form (vial, pen) and insulin type (rapid-acting, short-acting, intermediate-acting, and long-acting).In 2021, a total of 1,635 enhanced Part D plans will participate in this model, which represents just over 30% of both PDPs (310 plans) and MA-PDs (1,325 plans) available in 2021, including plans in the territories. Between 8 and 10 enhanced PDPs in each region are participating in the model, in addition to multiple MA-PDs (see map).

    The average premium in 2021 for the subset of enhanced PDPs participating in the insulin $35 copay model ($59) is nearly twice as high as the monthly premium for basic ajanta pharma kamagra price PDPs ($33) and 61% higher than the average premium for enhanced PDPs that are not participating in the model ($37) (weighted by September 2020 enrollment). Part D Cost SharingPart D Enrollees Will Pay Much Higher Cost-Sharing Amounts for Brands and Non-preferred Drugs Than For Drugs on a Generic Tier, and a Mix of Copays and Coinsurance for Different Formulary TiersFigure 7. In 2021, Part D Enrollees Will Pay Much Higher Cost-Sharing Amounts for Brands and Non-preferred Drugs than for Drugs on a Generic Tier, and a Mix of Copays and Coinsurance for Different Formulary Tiers​In 2021, as in prior years, Part D enrollees ajanta pharma kamagra price will face much higher cost-sharing amounts for brands and non-preferred drugs (which can include both brands and generics) than for drugs on a generic tier, and a mix of copayments and coinsurance for different formulary tiers (Figure 7). The typical five-tier formulary design in Part D includes tiers for preferred generics, generics, preferred brands, non-preferred drugs, and specialty drugs. Among all PDPs, median standard cost sharing ajanta pharma kamagra price in 2021 is $0 for preferred generics and $5 for generics (an increase from $4 in 2020), $40 for preferred brands (a decrease from $42 in 2020), 40% coinsurance for non-preferred drugs (an increase from 38% in 2020.

    The maximum allowed is 50%), and 25% coinsurance for specialty drugs (the same as in 2020. The maximum allowed is 33%).Among the 21 national PDPs, 13 PDPs, covering 9.3 million enrollees as of September 2020, are increasing cost-sharing amounts for drugs on at least one formulary ajanta pharma kamagra price tier between 2020 and 2021 (Table 3). Five PDPs are increasing copayments for ajanta pharma kamagra price generics, with increases ranging from $1 to $4. Six PDPs are increasing copayments for preferred brands, with increases ranging from $3 to $10. And 10 PDPs are increasing coinsurance for non-preferred drugs, with increases ranging from 2 percentage points (e.g., from a 38% coinsurance rate to 40%) to 14 percentage points (e.g., from a 35% coinsurance rate to 49%).Low-Income ajanta pharma kamagra price Subsidy Plan AvailabilityIn 2021, 259 Part D Stand-Alone Drug Plans Will Be Premium-Free to Enrollees Receiving the Low-Income Subsidy (Benchmark Plans)Figure 8.

    In 2021, 259 Part D Stand-Alone Drug Plans Will Be Available Without a Premium to Enrollees Receiving the Low-Income Subsidy (“Benchmark” Plans)​In 2021, a larger number of PDPs will be premium-free benchmark plans—that is, PDPs available for no monthly premium to Medicare Part D enrollees receiving the Low-Income Subsidy (LIS)—than in recent years, with 259 premium-free benchmark plans, or roughly a quarter of all PDPs in 2021 (Figure 8). Through the Part D LIS ajanta pharma kamagra price program, enrollees with low incomes and modest assets are eligible for assistance with Part D plan premiums and cost sharing. As of 2020, approximately 13 million Part D enrollees are receiving LIS, including 6.7 million (52%) in PDPs and 6.1 million (48%) in MA-PDs.On average (weighted by Medicare enrollment), LIS beneficiaries have eight benchmark plans available to them for 2021, or about one-fourth the average number of PDP choices available overall. All LIS ajanta pharma kamagra price enrollees can select any plan offered in their area, but if they enroll in a non-benchmark plan, they must pay some portion of their chosen plan’s monthly premium. In 2021, 10% of all LIS PDP enrollees who are eligible for premium-free Part D coverage (0.6 million LIS enrollees) will pay Part D premiums averaging $33 per month unless they switch or are reassigned by CMS to premium-free plans.The number of benchmark plans available in 2021 will vary by region, from five to 10 (see map).

    In 2020, ajanta pharma kamagra price 89% of the 6.6 million LIS PDP enrollees are projected to be in PDPs operated by five firms. CVS Health, Centene, Humana, UnitedHealth, and Cigna (based on 2020 enrollment). DiscussionOur analysis of the Medicare Part D ajanta pharma kamagra price stand-alone drug plan landscape for 2021 shows that millions of Part D enrollees without low-income subsidies will face premium and other cost increases in 2021 if they stay in their current stand-alone drug plan. There are more plans available nationwide in 2021, with Medicare beneficiaries having 30 PDP choices during this year’s open enrollment period, plus 27 Medicare Advantage drug plan options. Most Part D PDP enrollees who remain in the same plan in 2021 will be in a plan with the standard $445 deductible and will face much higher cost sharing for brands than for generic drugs, including as much as 50% coinsurance for non-preferred drugs.Some Part D enrollees who choose to stay in their current plans may see lower premiums and other costs for their drug coverage, ajanta pharma kamagra price but nearly 8 in 10 non-LIS enrollees will face higher premiums if they remain in their current plan, and many will also face higher deductibles and cost sharing for covered drugs.

    Some beneficiaries might find the best coverage and costs for their specific medications in a plan with a relatively low premium, while for other beneficiaries, a higher-premium plan might be more suitable. Because Part D plans vary in a number of ways that can have a significant effect on an enrollee’s out-of-pocket spending, beyond the ajanta pharma kamagra price monthly premium, all Part D enrollees could benefit from the opportunity to compare plans during open enrollment.Juliette Cubanski is with KFF.Anthony Damico is an independent consultant. This analysis focuses on the Medicare Part D stand-alone prescription drug plan marketplace in 2021 and trends over time. The analysis includes 20.2 million enrollees in stand-alone PDPs, as of ajanta pharma kamagra price March 2020. The analysis excludes 17.4 million MA-PD enrollees (non-employer), and another 4.6 million enrollees in employer-group only PDPs and 2.3 million in employer-group only MA-PDs for whom plan premium and benefits data are unavailable.Data on Part D plan availability, enrollment, and premiums were collected from a set of data files released by the Centers for Medicare &.

    Medicaid Services (CMS):– Part D plan landscape files, released each fall prior to the annual enrollment period– Part D plan and premium files, ajanta pharma kamagra price released each fall– Part D plan crosswalk files, released each fall– Part D contract/plan/state/county level enrollment files, released on a monthly basis– Part D Low-Income Subsidy enrollment files, released each spring– Medicare plan benefit package files, released each fallIn this analysis, premium estimates are weighted by September 2020 enrollment unless otherwise noted. Percentage increases are calculated based on non-rounded estimates and in some cases differ from percentage calculations calculated based on rounded estimates presented in the text..

    During the Medicare open lowest price kamagra enrollment period from October 15 to December 7 each year, beneficiaries can enroll in a plan that provides Part D drug coverage, either a stand-alone prescription https://captura.uk.com/ drug plan (PDP) as a supplement to traditional Medicare, or a Medicare Advantage prescription drug plan (MA-PD), which covers all Medicare benefits, including drugs. Among the 46 million Part lowest price kamagra D enrollees in 2020, 20.2 million (44%) are in PDPs and 19.3 million (41%) are in MA-PDs (excluding the 7.0 million (15%) in employer-only group PDPs and MA-PDs). This issue brief provides an overview of Medicare Part D drug plans that will be available in 2021 and key trends over time.Part D Plan AvailabilityThe Average Medicare Beneficiary Has a Choice of Nearly 60 Medicare Plans with Part D Drug Coverage in 2021, Including 30 Medicare Stand-alone Drug Plans and 27 Medicare Advantage Drug PlansFigure 1. The Average Medicare lowest price kamagra Beneficiary Has a Choice of Nearly 60 Medicare Plans Offering Drug Coverage in 2021, Including 30 Stand-alone Drug Plans and 27 Medicare Advantage Drug PlansA larger number of Part D plans will be offered in 2021 than in recent years.

    The average Medicare beneficiary will have a choice of 30 stand-alone PDPs in 2021, two more PDP options than in 2020, and eight more than in 2017, a 36% increase (Figure 1). Although the number of PDP options in 2021 is half of what it was at the peak in lowest price kamagra 2007 (when there were 56 PDP options, on average), this is the fourth year in a row with an increase in the average number of stand-alone drug plan options.In 2021, beneficiaries will also have access to 27 MA-PDs, on average, a 71% increase in MA-PD options since 2017 (excluding Medicare Advantage plans that do not offer the drug benefit and plans not available to all beneficiaries. Overall, an average of 33 Medicare Advantage plan options will be available in 2021).Based on September 2020 enrollment, 8 out of 10 PDP enrollees (80%) in 2021 are projected to be in PDPs operated by just four firms. UnitedHealth, Centene (which acquired WellCare in 2020), Humana, and CVS Health (based on PDP enrollment as of September lowest price kamagra 2020).

    All four firms offer PDPs in all 34 PDP regions in 2021.A Total of 996 Medicare Part D Stand-Alone Prescription Drug Plans Will Be Offered in 2021, a 5% Increase From 2020 and a 34% Increase Since 2017 Figure 2. A Total of 996 Medicare Part D Stand-Alone Prescription Drug Plans Will Be Offered in 2021, a 5% Increase From 2020 and a 34% Increase Since lowest price kamagra 2017​A total of 996 PDPs will be offered in the 34 PDP regions in 2021 (plus another 11 PDPs in the territories), an increase of 48 PDPs (5%) over 2020, and 250 more PDPs (a 34% increase) since 2017 (Figure 2). This increase is primarily due to the Trump Administration’s elimination of the “meaningful difference” requirement for enhanced benefit PDPs offered by the same organization in the same region. Eliminating this requirement means that PDP sponsors no longer have to demonstrate lowest price kamagra that their enhanced PDPs offered in the same region are meaningfully different in terms of enrollee out-of-pocket costs.

    In 2021, 62% of PDPs (618 plans) will offer enhanced Part D benefits—a 60% increase in the availability of enhanced-benefit PDPs since 2017, when just over half of PDPs (387 plans) offered enhanced benefits.The number of PDPs per region in 2021 will range from 25 PDPs in Alaska to 35 PDPs in Texas and will be the same or higher in 32 of the 34 PDP regions compared to 2020 (see map, Table 1). Part D PremiumsThe Estimated Average Monthly Premium for Medicare PDPs Is Projected to Increase by 9% lowest price kamagra to $41 in 2021, Based on Current EnrollmentFigure 3. The Estimated Average Monthly Premium for Medicare PDPs Is Projected to Increase by 9% to $41 in 2021, Based on Current Enrollment​The estimated national average monthly PDP premium for 2021 is projected to increase by 9% to $41, from $38 in 2021, weighted by September 2020 enrollment (Figure 3). It is likely that the actual lowest price kamagra average weighted premium for 2021, after taking into account enrollment choices by new enrollees and plan changes by current enrollees, will be somewhat lower than the estimated average.

    CMS reported that the average premium for basic Part D coverage offered by PDPs and MA-PDs will be an estimated $30 in 2021. Our premium estimate is higher because it is based on lowest price kamagra PDPs only (excluding MA-PDs) and includes PDPs offering both basic and enhanced coverage (enhanced plans, which account for 62% of all PDPs in 2021, have higher premiums than basic plans, on average).Average Monthly Premiums for the 21 National Part D Stand-alone PDPs Are Projected to Range from $7 to $89 in 2021, with Higher Average Premiums for Enhanced Benefits and Zero-Deductible PDPsFigure 4. Average Monthly Premiums for the 21 National Part D Stand-alone Drug Plans Are Projected to Range from $7 to $89 in 2021​PDP premiums will vary widely across plans in 2021, as in previous years (Figure 4, Table 2). Among the 21 PDPs available nationwide, average premiums will range from a low of $7 per month for SilverScript SmartRx to a high of $89 per month for AARP MedicareRx Preferred.Changes to premiums from 2020 to 2021, averaged across regions and weighted by 2020 enrollment, also vary widely across PDPs, as do the absolute amounts of monthly premiums for 2021.The 1.9 million non-LIS enrollees in the largest PDP, CVS Health’s SilverScript Choice (which had a total of 3.9 lowest price kamagra million enrollees in 2020, including those receiving low-income subsidies) will face a modest $1 (2%) decrease in their average monthly premium, from $29 in 2020 to $28 in 2021.In contrast, the 1.8 million non-LIS enrollees in the second largest PDP, AARP MedicareRx Preferred, will face a $10 (12%) increase in their average monthly premium between 2020 and 2021, from $79 to $89.

    This is the highest monthly premium among the national PDPs in 2021.The 1.3 million non-LIS enrollees in the fourth largest PDP, Humana Premier Rx, will see a $7 (13%) increase in their monthly premium, from $58 in 2020 to $65 in 2021.Most Part D stand-alone drug plans in 2021 (62% of PDPs) will offer enhanced benefits for a higher monthly lowest price kamagra premium. Enhanced benefits can include a lower (or no) deductible, reduced cost sharing, or a higher initial coverage limit than under the standard benefit design. The average premium in 2021 for enhanced benefit PDPs is $51, which is 55% higher than the monthly premium for PDPs offering the basic benefit ($33) (weighted by September 2020 enrollment).In 2021, a large majority of PDPs lowest price kamagra (86%) will charge a deductible, with most PDPs (67%) charging the standard amount of $445 in 2021. Across all PDPs, the average deductible in 2021 will be $345 (weighted by September 2020 enrollment).

    The average monthly premium in 2021 lowest price kamagra for PDPs that charge no deductible is $88, nearly three times the monthly premium for PDPs that charge the standard deductible ($34) or a partial deductible ($31) (weighted by September 2020 enrollment).Nearly 8 in 10 Part D Stand-alone Drug Plan Enrollees Without Low-income Subsidies Will Pay Higher Premiums in 2021 If They Stay in Their Current PlanFigure 5. Nearly 8 in 10 Part D Stand-alone Drug Plan Enrollees Without Low-income Subsidies Will Pay Higher Premiums in 2021 If They Stay in Their Current Plan​Most (78%, or 10 million) of the 13.4 million Part D PDP enrollees who are responsible for paying the entire premium (which excludes Low-Income Subsidy (LIS) recipients) will see their monthly premium increase in 2021 if they stay in their same plan, while 2.8 million (21%) will see a premium reduction if they stay in their same plan (Figure 5).Nearly 2 million non-LIS enrollees (13%) will see a premium increase of $10 or more per month, while significantly fewer (0.2 million non-LIS enrollees, or 1%) will see a premium reduction of the same magnitude. One-third (34%) of non-LIS enrollees (4.6 million) are projected to pay monthly premiums of at least $60 if they stay in their current plans, and lowest price kamagra more than 230,000 (2% of non-LIS enrollees) are projected to pay monthly premiums of at least $100.The Average Monthly Part D Premium in 2021 for the Subset of Enhanced Stand-alone Drug Plans Covering Insulin at a $35 Monthly Copay Is Substantially Higher Than Premiums for Other PDPsFigure 6. The Average Monthly Part D Premium in 2021 for the Subset of Enhanced Stand-alone Drug Plans Covering Insulin at a $35 Monthly Copay is Substantially Higher than Premiums for Other Plans​New for 2021, beneficiaries in each state will have the option to enroll in a Part D plan participating in the Trump Administration’s new Innovation Center model in which enhanced drug plans cover insulin products at a monthly copayment of $35 in the deductible, initial coverage, and coverage gap phases of the Part D benefit.

    Participating plans do not have to cover all insulin products at the $35 monthly copayment amount, just one of each dosage form (vial, pen) and http://jeffreymetcalfe.com/testimonials/ insulin type (rapid-acting, short-acting, lowest price kamagra intermediate-acting, and long-acting).In 2021, a total of 1,635 enhanced Part D plans will participate in this model, which represents just over 30% of both PDPs (310 plans) and MA-PDs (1,325 plans) available in 2021, including plans in the territories. Between 8 and 10 enhanced PDPs in each region are participating in the model, in addition to multiple MA-PDs (see map). The average premium in 2021 for the subset of enhanced PDPs participating in the insulin $35 copay model ($59) is lowest price kamagra nearly twice as high as the monthly premium for basic PDPs ($33) and 61% higher than the average premium for enhanced PDPs that are not participating in the model ($37) (weighted by September 2020 enrollment). Part D Cost SharingPart D Enrollees Will Pay Much Higher Cost-Sharing Amounts for Brands and Non-preferred Drugs Than For Drugs on a Generic Tier, and a Mix of Copays and Coinsurance for Different Formulary TiersFigure 7.

    In 2021, Part D Enrollees Will Pay Much Higher Cost-Sharing Amounts for Brands and Non-preferred Drugs than for Drugs on a Generic Tier, and a Mix of Copays and Coinsurance for Different Formulary Tiers​In 2021, as in prior years, Part D enrollees will face much higher cost-sharing amounts for brands and non-preferred drugs (which can include lowest price kamagra both brands and generics) than for drugs on a generic tier, and a mix of copayments and coinsurance for different formulary tiers (Figure 7). The typical five-tier formulary design in Part D includes tiers for preferred generics, generics, preferred brands, non-preferred drugs, and specialty drugs. Among all PDPs, median standard cost sharing in 2021 is $0 for preferred generics and $5 for generics (an increase from $4 in 2020), $40 for preferred brands (a decrease from $42 in 2020), 40% coinsurance for lowest price kamagra non-preferred drugs (an increase from 38% in 2020. The maximum allowed is 50%), and 25% coinsurance for specialty drugs (the same as in 2020.

    The maximum allowed is 33%).Among the 21 national PDPs, 13 PDPs, covering 9.3 million enrollees as of September 2020, are increasing cost-sharing amounts for lowest price kamagra drugs on at least one formulary tier between 2020 and 2021 (Table 3). Five PDPs are increasing copayments for generics, with increases ranging from $1 to $4 lowest price kamagra. Six PDPs are increasing copayments for preferred brands, with increases ranging from $3 to $10. And 10 PDPs are increasing coinsurance for non-preferred drugs, with increases ranging from 2 percentage points (e.g., from a 38% coinsurance rate to 40%) to 14 percentage points (e.g., from a 35% coinsurance rate to 49%).Low-Income Subsidy Plan AvailabilityIn 2021, 259 Part D Stand-Alone Drug Plans Will Be Premium-Free to Enrollees Receiving lowest price kamagra the Low-Income Subsidy (Benchmark Plans)Figure 8.

    In 2021, 259 Part D Stand-Alone Drug Plans Will Be Available Without a Premium to Enrollees Receiving the Low-Income Subsidy (“Benchmark” Plans)​In 2021, a larger number of PDPs will be premium-free benchmark plans—that is, PDPs available for no monthly premium to Medicare Part D enrollees receiving the Low-Income Subsidy (LIS)—than in recent years, with 259 premium-free benchmark plans, or roughly a quarter of all PDPs in 2021 (Figure 8). Through the Part D LIS program, enrollees with low incomes and modest assets are eligible for assistance with Part D plan lowest price kamagra premiums and cost sharing. As of 2020, approximately 13 million Part D enrollees are receiving LIS, including 6.7 million (52%) in PDPs and 6.1 million (48%) in MA-PDs.On average (weighted by Medicare enrollment), LIS beneficiaries have eight benchmark plans available to them for 2021, or about one-fourth the average number of PDP choices available overall. All LIS lowest price kamagra enrollees can select any plan offered in their area, but if they enroll in a non-benchmark plan, they must pay some portion of their chosen plan’s monthly premium.

    In 2021, 10% of all LIS PDP enrollees who are eligible for premium-free Part D coverage (0.6 million LIS enrollees) will pay Part D premiums averaging $33 per month unless they switch or are reassigned by CMS to premium-free plans.The number of benchmark plans available in 2021 will vary by region, from five to 10 (see map). In 2020, lowest price kamagra 89% of the 6.6 million LIS PDP enrollees are projected to be in PDPs operated by five firms. CVS Health, Centene, Humana, UnitedHealth, and Cigna (based on 2020 enrollment). DiscussionOur analysis of the Medicare Part D stand-alone drug plan landscape for 2021 shows that millions of Part D enrollees without low-income subsidies will face premium and other cost increases in 2021 if they stay in lowest price kamagra their current stand-alone drug plan.

    There are more plans available nationwide in 2021, with Medicare beneficiaries having 30 PDP choices during this year’s open enrollment period, plus 27 Medicare Advantage drug plan options. Most Part D PDP enrollees who remain in the same plan in 2021 will be in a plan with the standard $445 deductible and lowest price kamagra will face much higher cost sharing for brands than for generic drugs, including as much as 50% coinsurance for non-preferred drugs.Some Part D enrollees who choose to stay in their current plans may see lower premiums and other costs for their drug coverage, but nearly 8 in 10 non-LIS enrollees will face higher premiums if they remain in their current plan, and many will also face higher deductibles and cost sharing for covered drugs. Some beneficiaries might find the best coverage and costs for their specific medications in a plan with a relatively low premium, while for other beneficiaries, a higher-premium plan might be more suitable. Because Part D plans vary in a number of ways that can have a significant effect on an enrollee’s out-of-pocket spending, beyond the monthly premium, all Part D enrollees could lowest price kamagra benefit from the opportunity to compare plans during open enrollment.Juliette Cubanski is with KFF.Anthony Damico is an independent consultant.

    This analysis focuses on the Medicare Part D stand-alone prescription drug plan marketplace in 2021 and trends over time. The analysis lowest price kamagra includes 20.2 million enrollees in stand-alone PDPs, as of March 2020. The analysis excludes 17.4 million MA-PD enrollees (non-employer), and another 4.6 million enrollees in employer-group only PDPs and 2.3 million in employer-group only MA-PDs for whom plan premium and benefits data are unavailable.Data on Part D plan availability, enrollment, and premiums were collected from a set of data files released by the Centers for Medicare &. Medicaid Services (CMS):– Part D plan landscape files, released each fall prior lowest price kamagra to the annual enrollment period– Part D plan and premium files, released each fall– Part D plan crosswalk files, released each fall– Part D contract/plan/state/county level enrollment files, released on a monthly basis– Part D Low-Income Subsidy enrollment files, released each spring– Medicare plan benefit package files, released each fallIn this analysis, premium estimates are weighted by September 2020 enrollment unless otherwise noted.

    Percentage increases are calculated based on non-rounded estimates and in some cases differ from percentage calculations calculated based on rounded estimates presented in the text..

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    The college football season is kicking into high gear, https://www.korneeldeclercq.be/2017/12/27/hello-world-2/ the kamagra reviews does work National Football League season starts Sept. 9, and the baseball pennant races are heating up. For the first time since 2019, nearly all stadiums will be fully open to fans. In the so-called Before Times, sitting shoulder to shoulder inside a stadium with tens of thousands of boisterous spectators kamagra reviews does work — after a few hours of pregame tailgating — was a highlight of many fans’ autumn.

    But with erectile dysfunction treatment cases, hospitalizations and deaths soaring from the delta variant, many fans are wondering if that is a wise idea. KHN talked to seven health experts to get their takes. 1. Is it safe to go to a packed stadium even if you are vaccinated?.

    Six out of the seven public health experts that KHN spoke to from big football states were adamant in their response. No way. Not now. €œI am a die-hard sports fan,” said Jason Salemi, an associate professor of epidemiology at the University of South Florida in Tampa.

    €œBut I would not go to these events right now.” Salemi said that with erectile dysfunction treatment cases at their highest level since late January — with the seven-day average case count rising to just over 149,000 as of Monday — and hospitals filling up around the country, there is too much risk even for people who have been fully vaccinated against erectile dysfunction treatment. While outdoor events are less likely to lead to because the air circulation is greater, sitting within just a few feet of 10 or 20 screaming fans watching football, baseball, soccer or an auto race at a stadium reduces that safety margin, he said. treatments greatly lower your risk of being hospitalized or dying from erectile dysfunction treatment, but the dominance of the more transmissible delta variant is leading to increasing numbers of breakthrough s, some of which do cause uncomfortable symptoms. Getting infected also increases the likelihood of passing the to unvaccinated people, who could become seriously ill.

    Even some vaccinated fans — especially those who are older and frail or people with chronic medical conditions — should also realize they face higher risk from an . The Centers for Disease Control and Prevention does not specifically have guidance about sporting events, but it recommends that anyone attending large gatherings in areas with high numbers of erectile dysfunction treatment cases should “consider wearing a mask in crowded outdoor settings and for activities with close contact” with others who are not fully vaccinated. €œA packed football stadium now is not a good idea,’’ said Dr. Olveen Carrasquillo, a professor of medicine and public health sciences at the University of Miami’s medical school.

    €œWhen there’s a lot of shouting and yelling’’ without masks, “it means they’re spraying the kamagra.’’ Football stadiums, which are generally among the largest sporting venues in this country, are typically packed with fans cheering and high-fiving, making it impossible to physically distance from people who may be unvaccinated. Equally difficult is remaining apart from the unvaccinated in crowded concourses and restrooms. Dr. Robert Siegel, a professor of microbiology and immunology at Stanford University, said that while the risk of dying or ending up in intensive care from erectile dysfunction treatment after being vaccinated is “vanishingly small,” he would prefer to even avoid a milder case so he doesn’t have to worry about long-term consequences of the disease.

    €œIt’s not worth it to me, but if football is your life, you may have a different calculus,” he said. 2. What can I do to reduce my risk at the game?. The first line of defense is being fully vaccinated.

    If unvaccinated, don’t go to the game, all seven experts strongly recommended. Some colleges such as Louisiana State University are requiring fans to be vaccinated or to show a negative erectile dysfunction treatment test to attend a game — and many players on teams are vaccinated to reduce their risk and stay in the game. But many stadiums will have no such restriction on fans. Wear a mask except when eating or drinking.

    Mask mandates vary by venue for both the NFL and college teams. Even if others around you are not wearing one, your mask will give you a level of protection from inhaling the kamagra. €œIt’s best if all parties are wearing a mask, but wearing a mask is better than not wearing a mask,” said Dr. Nasia Safdar, a specialist in infectious diseases at the University of Wisconsin School of Medicine and Public Health.

    Dr. Dale Bratzler, Oklahoma University’s chief erectile dysfunction treatment officer, said he would not tell vaccinated people to avoid going to football games. He does strongly advise, however, that fans consider double masking. He doesn’t plan to go to the OU games this fall, but it has nothing to do with erectile dysfunction treatment.

    €œIt’s because of the traffic getting into and out of the stadium. I am fine watching at home on TV.” If you want to protect others, consider taking a home erectile dysfunction treatment test the day of the game. If the test results come back positive, or if you feel any symptoms, even a runny nose, mild headache, or cough, don’t go to a game, Safdar said. And the experts said to pay attention to the level of erectile dysfunction treatment cases in any city to which you are traveling.

    The incidence could be high, and that should factor into your decision about attending a game. 3. What about tailgating for hours with friends before the game?. Most of the experts agreed tailgating with a few friends outdoors is a less risky part of the football game experience.

    But that’s only if you know the people you are eating and drinking with are vaccinated. €œIt’s also that party atmosphere, where people are generally not in a position to wear a mask and you are standing close to people,” Safdar said. €œIt’s still a risk.” 4. Millions of people have been attending baseball games, soccer games and other sports events all summer — without many outbreaks.

    Why worry now about football games?. There have been rare reports of outbreaks from major league baseball stadiums, which often pack in 40,000 fans. But that could be changing, too, because the more highly transmissible delta variant has been widespread only since July. Also, the experts said, it’s difficult to track how many fans get sick because the incubation period can last a week or more.

    People may not connect their illness to the game, especially if they assume outdoor activities are safe. €œDelta changed the entire equation of how we looked at the risk,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University School of Medicine in Nashville. €œI do think there will be transmission’’ in stadiums.

    Health experts point to the Sturgis Motorcycle Rally in South Dakota last month that has been linked to more than 100 s. 5. Can I still get together with other vaccinated friends and family?. Even with the delta variant raging, health experts say people who are fully immunized can safely meet without masks with those they know are fully vaccinated.

    €œIf you know with certainty that someone is vaccinated, you can safely get together for dinner and other activities,” said Dr. Joseph Gastaldo, a specialist in infectious diseases at Ohio Health, a large, multihospital system based in Columbus. And the risk of spread can be minimized at events such as an outdoor wedding if organizers include requirements for vaccinations, wearing masks and physical distancing for vulnerable attendees, experts say. Phil Galewitz.

    pgalewitz@kff.org, @philgalewitz Andy Miller. amiller@kff.org, @gahealthnews Related Topics Contact Us Submit a Story TipGov. Gavin Newsom’s first term in office has been defined by his response to the erectile dysfunction treatment kamagra, which has claimed the lives of more than 65,400 Californians. The Democratic governor issued the first statewide stay-at-home order in the nation, and his policies kept most public school students at home last year.

    But his own children attended private school in person and, in a move that has haunted him since, he dined with friends and lobbyists at the ritzy French Laundry restaurant in the Napa Valley in November — even though state guidelines discouraged people from mixing with others outside their household. More recently, Newsom has required all health care workers to get fully vaccinated by the end of the month. But he has not ordered a new statewide mask mandate, despite the deadly spread of the kamagra’s delta variant. Newsom has said his policies are driven by science, but they have helped land him in an unexpectedly competitive recall election.

    A Public Policy Institute of California poll released Wednesday shows that about 58% of likely voters want to keep him in office. Voters, who have been mailed ballots, have until the Sept. 14 election date to return them. Many of Newsom’s Republican rivals, including talk-radio host Larry Elder, businessman John Cox and former San Diego mayor Kevin Faulconer, are focusing their opposition on Newsom’s mask and treatment policies.

    Just how much is the kamagra playing into voters’ decisions?. KHN reporters fanned out across the Golden State — visiting a fire evacuee camp in Placerville, outdoor malls in the Silicon Valley, Olvera Street in downtown Los Angeles and an urban park in Sacramento — to find out. Placerville The Walmart parking lot in the Sierra Nevada foothill town of Placerville is now temporary living quarters for dozens of families who have been forced to flee the Caldor Fire. The overwhelming sentiment at the evacuation site on Aug.

    27 was that http://www.maine--coon.de/maine-coon-katzen-die-sanften-riesen-im-portraet-video/ it’s time for Gov. Gavin Newsom to go. (Samantha Young / California Healthline) Denise Byer helped collect signatures to get the recall election on the ballot. She’s still upset that her children and millions of other California kids spent nearly a year distance-learning while Newsom’s children attended private school in person.

    (Samantha Young / California Healthline) In the Sierra Nevada foothills, many voters describe Newsom as a big-city elitist who issued kamagra mandates for the masses but played by his own rulebook. €œRECALL NEWSOM SAVE CALIFORNIA” signs line busy roads and plaster fences and storefronts in Placerville, home to about 11,000 people some 40 miles from California’s capital. Even a few evacuees from the raging Caldor Fire — whose homes and livelihoods are at stake — display anti-Newsom signs on their RVs and vans at their temporary outpost in the Walmart parking lot. The deep anger facing Newsom in El Dorado County isn’t unexpected.

    The area draws on Gold Rush-era independence. Several businesses flouted public health orders that required masks indoors. €œWhatever edict he put out there never applied to him,” said Denise Byer, 55, a volunteer at a wildfire evacuation site whose children missed nearly a year of in-person high school and competitive sports. €œHis own children went back to school.

    He’s an elite. He’s a hypocrite.” That was the overwhelming sentiment at two Placerville evacuation sites, where several people commented but asked not to be identified, some for fear of workplace repercussions. Newsom “sat up on high,” said a county worker. The governor wants to impose broad mandates on Californians that should be up to the people, said an evacuee who, like other state workers, must be vaccinated or submit to weekly erectile dysfunction treatment tests.

    Newsom “has ruled like a king,” chimed in an evacuee who didn’t know whether his home would survive the fires. €” Samantha Young Silicon Valley Meghan Purdy fears California may become more like Florida or Texas — whose governors she thinks mishandled the kamagra — if Newsom is recalled. She dropped her ballot off at the library as soon as she could. (Rachel Bluth / California Healthline) On a sunny, late-August Sunday, Palo Alto’s luxe University Avenue and San Jose’s trendy Santana Row, an outdoor shopping mall, were jammed, and the broad streets have been taken over by shopping, outdoor dining and live music.

    Signs occasionally reminded patrons to mask up in stores, but there was little evidence of the kamagra, and even less of the impending recall election. Both cities are in Santa Clara County, where registered Democrats outnumber Republicans 3-to-1. Gov. Gavin Newsom has been the only “adult in the room” making hard decisions about business shutdowns and masks, says Michael Burrows.

    He believes the recall is just theatrics from anti-vaxxers and Republicans. (Rachel Bluth / California Healthline) When it comes to the recall, there was only one answer. No. Obviously no.

    Have you seen who he’s running against?. “I’m really frustrated that the recall is even happening. The people who are running to replace him are going to undo a lot of his work and make it a lot riskier to be in California,” said Meghan Purdy, a 34-year-old product manager in Palo Alto. €œI have friends in Texas, and I worry about them.

    I have a dad in Florida. They have horrible governors, and the fact that it could happen to us is scary.” In a small but crowded park on Santana Row, Michael Burrows, a 56-year-old database administrator, listened to a band while a coffee line snaked around the musicians. Newsom handled the kamagra as well as he could have, Burrows said. The recall is a waste of time, and anti-maskers and anti-vaxxers are trying to tarnish Newsom’s reputation on a national stage, he said.

    €œNobody likes to wear a mask — I don’t like to wear a mask — but it’s what you have to do,” Burrows said. €œYou have to have an adult in the room.” — Rachel Bluth Los Angeles The sound of salsa music lingered in the air as people wandered the cobblestone paths along Olvera Street in downtown Los Angeles. The historical Mexican marketplace was a ghost town of shuttered shops during the height of the kamagra, but now bustles with customers— most of them Latino. Some had no idea about the recall election.

    Others said they favored the governor but wouldn’t be able to vote because they are undocumented immigrants. Most expressed support for Newsom. Antonio Ramos, 57, and Isabel Ceja, 48, a couple from Novato, California, were visiting family in Los Angeles on Saturday. Some of their relatives have had erectile dysfunction treatment, and they said they know what it’s like to worry if they will survive.

    €œWhat he’s done for the community has been beneficial,” Ramos said in Spanish. €œLike getting the treatments out to everyone and the mask mandate. It’s for the safety of everyone.” The couple plan to vote against the recall. €œI like him because he’s Catholic and does everything with transparency,” Ceja added.

    €œHe isn’t two-faced.” Veronica Ayón, 28, a Los Angeles mother of three, disagreed. €œI think he says one thing and then does another,” she said in Spanish. Veronica Ayón is unsure how she’ll vote on Sept. 14 but bristles at Newsom’s pro-vaccination policies.

    Ayón doesn’t want to vaccinate her daughter, who is turning 12 in November. €œIf I’m not vaccinated, why should she?. € she asks. (Heidi de Marco / California Healthline) Ayón isn’t vaccinated but said she always wears a mask.

    She is breastfeeding her baby girl and fears what a treatment could do to her. (The Centers for Disease Control and Prevention recommend pregnant and breastfeeding women get vaccinated.) She said she will probably vote against Newsom. €œHe wants to make it mandatory for kids to get vaccinated at 12,” said Ayón, whose eldest child is about to turn 12. €œShe’s my daughter.

    It’s my decision.” — Heidi de Marco Sacramento In Sacramento’s Oak Park, a largely African American, inner-city neighborhood that is rapidly gentrifying, people don’t seem motivated to vote. Anti-recall signs backing Newsom pepper grassy lawns in the city’s wealthier neighborhoods, but none were visible here, though there are Black Lives Matter signs on nearly every block — a couple of them praising Dolly Parton. Many Oak Park residents said Newsom has failed them. Emma Patterson is more concerned about making a living than voting in the Sept.

    14 recall election. Patterson lost housing for herself and her two grandkids, ages 6 and 10, in July after an apartment fire. €œI have more important things on my mind,” she says. (Angela Hart / California Healthline) McClatchy Park in the heart of Sacramento’s Oak Park, a largely African American neighborhood, is a popular hangout on nights and weekends.

    About a dozen people surveyed on a late-August Sunday said they didn’t plan to vote or were unmotivated to cast a ballot, arguing that the governor has not prioritized their welfare in the kamagra. (Angela Hart / California Healthline) “I tore up my ballot and threw it in the trash,” said 52-year-old Regina Davis, who gathered with friends at a park filled with people barbecuing and jamming to music — a Sunday tradition in the neighborhood. She backed Newsom in 2018 but said she doesn’t plan to vote, arguing that Newsom has prioritized wealthy Californians during the kamagra. Others said they hadn’t decided whether to vote.

    €œHe needs to step up,” said Cleo Brown, 39, who supported Newsom when he ran for governor but said she now feels let down because Newsom has not invested in day care and after-school programs that could help her and her two kids, ages 15 and 18. Her message to Newsom. €œDo something for our kids. They’re still hurting from the school shutdowns.” Emma Patterson, 57, voted for Newsom in 2018 but said she has other things to worry about than the recall.

    €œHe needs us to show up for him, but Black families are struggling,” Patterson said. Her apartment burned down in July, and she’s renting a room for herself and her two grandkids for $150 a week. €œVoting isn’t even on my mind,” she said. €” Angela Hart Rachel Bluth.

    rbluth@kff.org, @RachelHBluth Samantha Young. syoung@kff.org, @youngsamantha Heidi de Marco. heidid@kff.org, @Heidi_deMarco Angela Hart. ahart@kff.org, @ahartreports Related Topics Contact Us Submit a Story Tip.

    The college football season is kicking into high lowest price kamagra gear, the National Football League season starts Sept. 9, and the baseball pennant races are heating up. For the first time since 2019, nearly all stadiums will be fully open to fans. In the so-called Before Times, sitting shoulder to shoulder inside a stadium with tens of thousands of boisterous spectators — after a few lowest price kamagra hours of pregame tailgating — was a highlight of many fans’ autumn. But with erectile dysfunction treatment cases, hospitalizations and deaths soaring from the delta variant, many fans are wondering if that is a wise idea.

    KHN talked to seven health experts to get their takes. 1. Is it safe to go to a packed stadium even if you are vaccinated?. Six out of the seven public health experts that KHN spoke to from big football states were adamant in their response. No way.

    Not now. €œI am a die-hard sports fan,” said Jason Salemi, an associate professor of epidemiology at the University of South Florida in Tampa. €œBut I would not go to these events right now.” Salemi said that with erectile dysfunction treatment cases at their highest level since late January — with the seven-day average case count rising to just over 149,000 as of Monday — and hospitals filling up around the country, there is too much risk even for people who have been fully vaccinated against erectile dysfunction treatment. While outdoor events are less likely to lead to because the air circulation is greater, sitting within just a few feet of 10 or 20 screaming fans watching football, baseball, soccer or an auto race at a stadium reduces that safety margin, he said. treatments greatly lower your risk of being hospitalized or dying from erectile dysfunction treatment, but the dominance of the more transmissible delta variant is leading to increasing numbers of breakthrough s, some of which do cause uncomfortable symptoms.

    Getting infected also increases the likelihood of passing the to unvaccinated people, who could become seriously ill. Even some vaccinated fans — especially those who are older and frail or people with chronic medical conditions — should also realize they face higher risk from an . The Centers for Disease Control and Prevention does not specifically have guidance about sporting events, but it recommends that anyone attending large gatherings in areas with high numbers of erectile dysfunction treatment cases should “consider wearing a mask in crowded outdoor settings and for activities with close contact” with others who are not fully vaccinated. €œA packed football stadium now is not a good idea,’’ said Dr. Olveen Carrasquillo, a professor of medicine and public health sciences at the University of Miami’s medical school.

    €œWhen there’s a lot of shouting and yelling’’ without masks, “it means they’re spraying the kamagra.’’ Football stadiums, which are generally among the largest sporting venues in this country, are typically packed with fans cheering and high-fiving, making it impossible to physically distance from people who may be unvaccinated. Equally difficult is remaining apart from the unvaccinated in crowded concourses and restrooms. Dr. Robert Siegel, a professor of microbiology and immunology at Stanford University, said that while the risk of dying or ending up in intensive care from erectile dysfunction treatment after being vaccinated is “vanishingly small,” he would prefer to even avoid a milder case so he doesn’t have to worry about long-term consequences of the disease. €œIt’s not worth it to me, but if football is your life, you may have a different calculus,” he said.

    2. What can I do to reduce my risk at the game?. The first line of defense is being fully vaccinated. If unvaccinated, don’t go to the game, all seven experts strongly recommended. Some colleges such as Louisiana State University are requiring fans to be vaccinated or to show a negative erectile dysfunction treatment test to attend a game — and many players on teams are vaccinated to reduce their risk and stay in the game.

    But many stadiums will have no such restriction on fans. Wear a mask except when eating or drinking. Mask mandates vary by venue for both the NFL and college teams. Even if others around you are not wearing one, your mask will give you a level of protection from inhaling the kamagra. €œIt’s best if all parties are wearing a mask, but wearing a mask is better than not wearing a mask,” said Dr.

    Nasia Safdar, a specialist in infectious diseases at the University of Wisconsin School of Medicine and Public Health. Dr. Dale Bratzler, Oklahoma University’s chief erectile dysfunction treatment officer, said he would not tell vaccinated people to avoid going to football games. He does strongly advise, however, that fans consider double masking. He doesn’t plan to go to the OU games this fall, but it has nothing to do with erectile dysfunction treatment.

    €œIt’s because of the traffic getting into and out of the stadium. I am fine watching at home on TV.” If you want to protect others, consider taking a home erectile dysfunction treatment test the day of the game. If the test results come back positive, or if you feel any symptoms, even a runny nose, mild headache, or cough, don’t go to a game, Safdar said. And the experts said to pay attention to the level of erectile dysfunction treatment cases in any city to which you are traveling. The incidence could be high, and that should factor into your decision about attending a game.

    3. What about tailgating for hours with friends before the game?. Most of the experts agreed tailgating with a few friends outdoors is a less risky part of the football game experience. But that’s only if you know the people you are eating and drinking with are vaccinated. €œIt’s also that party atmosphere, where people are generally not in a position to wear a mask and you are standing close to people,” Safdar said.

    €œIt’s still a risk.” 4. Millions of people have been attending baseball games, soccer games and other sports events all summer — without many outbreaks. Why worry now about football games?. There have been rare reports of outbreaks from major league baseball stadiums, which often pack in 40,000 fans. But that could be changing, too, because the more highly transmissible delta variant has been widespread only since July.

    Also, the experts said, it’s difficult to track how many fans get sick because the incubation period can last a week or more. People may not connect their illness to the game, especially if they assume outdoor activities are safe. €œDelta changed the entire equation of how we looked at the risk,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University School of Medicine in Nashville. €œI do think there will be transmission’’ in stadiums.

    Health experts point to the Sturgis Motorcycle Rally in South Dakota last month that has been linked to more than 100 s. 5. Can I still get together with other vaccinated friends and family?. Even with the delta variant raging, health experts say people who are fully immunized can safely meet without masks with those they know are fully vaccinated. €œIf you know with certainty that someone is vaccinated, you can safely get together for dinner and other activities,” said Dr.

    Joseph Gastaldo, a specialist in infectious diseases at Ohio Health, a large, multihospital system based in Columbus. And the risk of spread can be minimized at events such as an outdoor wedding if organizers include requirements for vaccinations, wearing masks and physical distancing for vulnerable attendees, experts say. Phil Galewitz. pgalewitz@kff.org, @philgalewitz Andy Miller. amiller@kff.org, @gahealthnews Related Topics Contact Us Submit a Story TipGov.

    Gavin Newsom’s first term in office has been defined by his response to the erectile dysfunction treatment kamagra, which has claimed the lives of more than 65,400 Californians. The Democratic governor issued the first statewide stay-at-home order in the nation, and his policies kept most public school students at home last year. But his own children attended private school in person and, in a move that has haunted him since, he dined with friends and lobbyists at the ritzy French Laundry restaurant in the Napa Valley in November — even though state guidelines discouraged people from mixing with others outside their household. More recently, Newsom has required all health care workers to get fully vaccinated by the end of the month. But he has not ordered a new statewide mask mandate, despite the deadly spread of the kamagra’s delta variant.

    Newsom has said his policies are driven by science, but they have helped land him in an unexpectedly competitive recall election. A Public Policy Institute of California poll released Wednesday shows that about 58% of likely voters want to keep him in office. Voters, who have been mailed ballots, have until the Sept. 14 election date to return them. Many of Newsom’s Republican rivals, including talk-radio host Larry Elder, businessman John Cox and former San Diego mayor Kevin Faulconer, are focusing their opposition on Newsom’s mask and treatment policies.

    Just how much is the kamagra playing into voters’ decisions?. KHN reporters fanned out across the Golden State — visiting a fire evacuee camp in Placerville, outdoor malls in the Silicon Valley, Olvera Street in downtown Los Angeles and an urban park in Sacramento — to find out. Placerville The Walmart parking lot in the Sierra Nevada foothill town of Placerville is now temporary living quarters for dozens of families who have been forced to flee the Caldor Fire. The overwhelming sentiment at the evacuation site on Aug. 27 was that it’s time for Gov.

    Gavin Newsom to go. (Samantha Young / California Healthline) Denise Byer helped collect signatures to get the recall election on the ballot. She’s still upset that her children and millions of other California kids spent nearly a year distance-learning while Newsom’s children attended private school in person. (Samantha Young / California Healthline) In the Sierra Nevada foothills, many voters describe Newsom as a big-city elitist who issued kamagra mandates for the masses but played by his own rulebook. €œRECALL NEWSOM SAVE CALIFORNIA” signs line busy roads and plaster fences and storefronts in Placerville, home to about 11,000 people some 40 miles from California’s capital.

    Even a few evacuees from the raging Caldor Fire — whose homes and livelihoods are at stake — display anti-Newsom signs on their RVs and vans at their temporary outpost in the Walmart parking lot. The deep anger facing Newsom in El Dorado County isn’t unexpected. The area draws on Gold Rush-era independence. Several businesses flouted public health orders that required masks indoors. €œWhatever edict he put out there never applied to him,” said Denise Byer, 55, a volunteer at a wildfire evacuation site whose children missed nearly a year of in-person high school and competitive sports.

    €œHis own children went back to school. He’s an elite. He’s a hypocrite.” That was the overwhelming sentiment at two Placerville evacuation sites, where several people commented but asked not to be identified, some for fear of workplace repercussions. Newsom “sat up on high,” said a county worker. The governor wants to impose broad mandates on Californians that should be up to the people, said an evacuee who, like other state workers, must be vaccinated or submit to weekly erectile dysfunction treatment tests.

    Newsom “has ruled like a king,” chimed in an evacuee who didn’t know whether his home would survive the fires. €” Samantha Young Silicon Valley Meghan Purdy fears California may become more like Florida or Texas — whose governors she thinks mishandled the kamagra — if Newsom is recalled. She dropped her ballot off at the library as soon as she could. (Rachel Bluth / California Healthline) On a sunny, late-August Sunday, Palo Alto’s luxe University Avenue and San Jose’s trendy Santana Row, an outdoor shopping mall, were jammed, and the broad streets have been taken over by shopping, outdoor dining and live music. Signs occasionally reminded patrons to mask up in stores, but there was little evidence of the kamagra, and even less of the impending recall election.

    Both cities are in Santa Clara County, where registered Democrats outnumber Republicans 3-to-1. Gov. Gavin Newsom has been the only “adult in the room” making hard decisions about business shutdowns and masks, says Michael Burrows. He believes the recall is just theatrics from anti-vaxxers and Republicans. (Rachel Bluth / California Healthline) When it comes to the recall, there was only one answer.

    No. Obviously no. Have you seen who he’s running against?. “I’m really frustrated that the recall is even happening. The people who are running to replace him are going to undo a lot of his work and make it a lot riskier to be in California,” said Meghan Purdy, a 34-year-old product manager in Palo Alto.

    €œI have friends in Texas, and I worry about them. I have a dad in Florida. They have horrible governors, and the fact that it could happen to us is scary.” In a small but crowded park on Santana Row, Michael Burrows, a 56-year-old database administrator, listened to a band while a coffee line snaked around the musicians. Newsom handled the kamagra as well as he could have, Burrows said. The recall is a waste of time, and anti-maskers and anti-vaxxers are trying to tarnish Newsom’s reputation on a national stage, he said.

    €œNobody likes to wear a mask — I don’t like to wear a mask — but it’s what you have to do,” Burrows said. €œYou have to have an adult in the room.” — Rachel Bluth Los Angeles The sound of salsa music lingered in the air as people wandered the cobblestone paths along Olvera Street in downtown Los Angeles. The historical Mexican marketplace was a ghost town of shuttered shops during the height of the kamagra, but now bustles with customers— most of them Latino. Some had no idea about the recall election. Others said they favored the governor but wouldn’t be able to vote because they are undocumented immigrants.

    Most expressed support for Newsom. Antonio Ramos, 57, and Isabel Ceja, 48, a couple from Novato, California, were visiting family in Los Angeles on Saturday. Some of their relatives have had erectile dysfunction treatment, and they said they know what it’s like to worry if they will survive. €œWhat he’s done for the community has been beneficial,” Ramos said in Spanish. €œLike getting the treatments out to everyone and the mask mandate.

    It’s for the safety of everyone.” The couple plan to vote against the recall. €œI like him because he’s Catholic and does everything with transparency,” Ceja added. €œHe isn’t two-faced.” Veronica Ayón, 28, a Los Angeles mother of three, disagreed. €œI think he says one thing and then does another,” she said in Spanish. Veronica Ayón is unsure how she’ll vote on Sept.

    14 but bristles at Newsom’s pro-vaccination policies. Ayón doesn’t want to vaccinate her daughter, who is turning 12 in November. €œIf I’m not vaccinated, why should she?. € she asks. (Heidi de Marco / California Healthline) Ayón isn’t vaccinated but said she always wears a mask.

    She is breastfeeding her baby girl and fears what a treatment could do to her. (The Centers for Disease Control and Prevention recommend pregnant and breastfeeding women get vaccinated.) She said she will probably vote against Newsom. €œHe wants to make it mandatory for kids to get vaccinated at 12,” said Ayón, whose eldest child is about to turn 12. €œShe’s my daughter. It’s my decision.” — Heidi de Marco Sacramento In Sacramento’s Oak Park, a largely African American, inner-city neighborhood that is rapidly gentrifying, people don’t seem motivated to vote.

    Anti-recall signs backing Newsom pepper grassy lawns in the city’s wealthier neighborhoods, but none were visible here, though there are Black Lives Matter signs on nearly every block — a couple of them praising Dolly Parton. Many Oak Park residents said Newsom has failed them. Emma Patterson is more concerned about making a living than voting in the Sept. 14 recall election. Patterson lost housing for herself and her two grandkids, ages 6 and 10, in July after an apartment fire.

    €œI have more important things on my mind,” she says. (Angela Hart / California Healthline) McClatchy Park in the heart of Sacramento’s Oak Park, a largely African American neighborhood, is a popular hangout on nights and weekends. About a dozen people surveyed on a late-August Sunday said they didn’t plan to vote or were unmotivated to cast a ballot, arguing that the governor has not prioritized their welfare in the kamagra. (Angela Hart / California Healthline) “I tore up my ballot and threw it in the trash,” said 52-year-old Regina Davis, who gathered with friends at a park filled with people barbecuing and jamming to music — a Sunday tradition in the neighborhood. She backed Newsom in 2018 but said she doesn’t plan to vote, arguing that Newsom has prioritized wealthy Californians during the kamagra.

    Others said they hadn’t decided whether to vote. €œHe needs to step up,” said Cleo Brown, 39, who supported Newsom when he ran for governor but said she now feels let down because Newsom has not invested in day care and after-school programs that could help her and her two kids, ages 15 and 18. Her message to Newsom. €œDo something for our kids. They’re still hurting from the school shutdowns.” Emma Patterson, 57, voted for Newsom in 2018 but said she has other things to worry about than the recall.

    €œHe needs us to show up for him, but Black families are struggling,” Patterson said. Her apartment burned down in July, and she’s renting a room for herself and her two grandkids for $150 a week. €œVoting isn’t even on my mind,” she said. €” Angela Hart Rachel Bluth. rbluth@kff.org, @RachelHBluth Samantha Young.

    syoung@kff.org, @youngsamantha Heidi de Marco. heidid@kff.org, @Heidi_deMarco Angela Hart. ahart@kff.org, @ahartreports Related Topics Contact Us Submit a Story Tip.

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