By Paula Span, KFF Health News

You’re ready to leave the hospital, but you don’t feel able to care for yourself at home yet.

Or, you’ve completed a couple of weeks in rehab. Can you handle your complicated medication regimen, along with shopping and cooking?

Perhaps you fell in the shower, and now your family wants you to arrange help with bathing and getting dressed.

There are facilities that provide such help, of course, but most older people don’t want to go there. They want to stay at home; that’s the problem.

When older people struggle with daily activities because they have grown frail, because their chronic illnesses have mounted, or because they have lost a spouse or companion, most don’t want to move. For decades, surveys have shown that they prefer to remain in their homes for as long as possible.

That means they need home care, either from family and friends, paid caregivers, or both. But paid home care represents an especially strained sector of the long-term care system, which is experiencing an intensifying labor shortage even as an aging population creates surging demand.

“It’s a crisis,” said Madeline Sterling, a primary care doctor at Weill Cornell Medicine and the director of Cornell University’s Initiative on Home Care Work. “It’s not really working for the people involved,” whether they are patients (who can also be younger people with disabilities), family members, or home care workers.

“This is not about what’s going to happen a decade from now,” said Steven Landers, chief executive of the National Alliance for Care at Home, an industry organization. “Do an Indeed.com search in Anytown, USA, for home care aides, and you’ll see so many listings for aides that your eyes will pop out.”

Against this grim backdrop, however, some alternatives show promise in upgrading home care jobs and in improving patient care. And they’re growing.

Some background: Researchers and elder care administrators have warned about this approaching calamity for years. Home care is already among the nation’s fastest-growing occupations, with 3.2 million home health aides and personal care aides on the job in 2024, up from 1.4 million a decade earlier, according to PHI, a research and advocacy group.

But the nation will need about 740,000 additional home care workers over the next decade, according to the Bureau of Labor Statistics, and recruiting them won’t be easy. Costs to consumers are high — the median hourly rate for a home health aide in 2024 was $34, the annual Genworth/CareScout survey shows, with big geographic variations. But an aide’s median hourly wage was less than $17.

These remain unstable, low-paying jobs. Of the largely female workforce, about a third of whom are immigrants, 40% live in low-income households and most receive some sort of public assistance.

Even if the agencies that employ them offer health insurance and they work enough hours to qualify, many cannot afford their premium payments.

Unsurprisingly, the turnover rate approaches 80% annually, according to a survey by the ICA Group, a nonprofit organization that promotes co-ops.

But not everywhere. One innovation, still small but expanding: home care cooperatives owned by the workers themselves. The first and largest, Cooperative Home Care Associates in the Bronx borough of New York City, began in 1985 and now employs about 1,600 home care aides. The ICA Group now counts 26 such worker-owned home care businesses nationwide.

“These co-ops are getting exceptional results,” said Geoffrey Gusoff, a family medicine doctor and health services researcher at UCLA. “They have half the turnover of traditional agencies, they hold onto clients twice as long, and they’re paying $2 more an hour” to their owner-employees.

When Gusoff and his co-authors interviewed co-op members for a qualitative study in JAMA Network Open, “we were expecting to hear more about compensation,” he said. “But the biggest single response was, ‘I have more say’” over working conditions, patient care, and the administration of the co-op itself.

“Workers say they feel more respected,” Gusoff said.

Through an initiative to provide financing, business coaching, and technical assistance, the ICA Group intends to boost the national total to 50 co-ops within five years and to 100 by 2040.

Another approach gaining ground: registries that allow home care workers and clients who need care to connect directly, often without involving agencies that provide supervision and background checks but also absorb roughly half the fee consumers pay.

One of the largest registries, Carina, serves workers and clients in Oregon and Washington. Established through agreements with the Service Employees International Union, the nation’s largest health care union, it serves 40,000 providers and 25,000 clients. (About 10% of home care workers are unionized, according to PHI’s analysis.)

Carina functions as a free, “digital hiring hall,” said Nidhi Mirani, its chief executive. Except in the Seattle area, it serves only clients who receive care through Medicaid, the largest funder of care at home. State agencies handle the paperwork and oversee background checks.

Hourly rates paid to independent providers found on Carina, which are set by union contracts, are usually lower than what agencies charge, while workers’ wages start at $20, and they receive health insurance, paid time off, and, in some cases, retirement benefits.

Other registries may be operated by states, as in Massachusetts and Wisconsin, or by platforms like Direct Care Careers, available in four states. “People are seeking a fit in who’s coming into their homes,” Mirani said. “And individual providers can choose their clients. It’s a two-way street.”

Finally, recent studies indicate ways that additional training for home care workers can pay off.

“These patients have complex conditions,” Sterling said of the aides. Home care workers, who take blood pressure readings, prepare meals, and help clients stay mobile, can spot troubling symptoms as they emerge.

Her team’s recent clinical trial of home health aides caring for patients with heart failure— “the No. 1 cause of hospitalization among Medicare beneficiaries,” Sterling pointed out — measured the effects of a 90-minute virtual training module about its symptoms and management.

“Leg swelling. Shortness of breath. They’re the first signs that the disease is not being controlled,” Sterling said.

In the study, involving 102 aides working for VNS Health, a large nonprofit agency in New York, the training was shown to enhance their knowledge and confidence in caring for clients with heart failure.

Moreover, when aides were given a mobile health app that allowed them to message their supervisors, they made fewer 911 calls and their patients made fewer emergency room visits.

Small-scale efforts like registries, co-ops, and training programs do not directly address home care’s most central problem: cost.

Medicaid underwrites home care for low-income older adults who have few assets, though the Trump administration’s new budget will slash Medicaid by more than $900 billion over the next decade. The well-off theoretically can pay out-of-pocket.

But “middle-class retired families either spend all their resources and essentially bankrupt themselves to become eligible for Medicaid, or they go without,” Landers said. Options like assisted living and nursing homes are even more expensive.

The United States has never committed to paying for long-term care for the middle class, and it seems unlikely to do so under this administration. Still, savings from innovations like these can reduce costs and might help expand home care through federal or state programs. Several tests and pilots are underway.

Home care workers “have a lot of insight into patients’ conditions,” Sterling said. “Training them and giving them technological tools shows that if we’re trying to keep patients at home, here’s a way to do that with the workforce that’s already there.”

The New Old Age is produced through a partnership with The New York Times.

©2026 KFF Health News. Distributed by Tribune Content Agency, LLC.

By Jolie Kerr

Special to The Washington Post

January is a great time of year to pick off decluttering projects, big and small. The new year, new you vibe can transform a task you’ve been putting off into one you cannot wait to cross off your to-do list.

And for many people, that overcrowded, overstuffed feeling the home can take on gives way to a burst of energy to get rid of it all.

Parting with your things, however, can be hard even when you’re excited at the prospect of a fresh start. Picking some easy(ish) decluttering projects is a great way to build momentum.

Here are 20 pretty easy things to consider removing from your home, your car or your life, in service of a less-cluttered 2026:

Holiday decorations

Start with the most obvious: As you take down holiday decor, weed out and throw away broken light sets and ornaments. (Will you need replacements? Order them now when you’re thinking of it, and they’re on sale.) Include holiday cards in the purge; keep the ones you want and throw away the rest.

Unwanted gifts

This one pushes the boundaries of “easy.” It can be hard to get rid of a gift that someone put thought and effort into. But if you got a gift you will truly never use, get rid of it. Return it, regift it, donate it, whatever the right move is, make it now. It won’t be easier in July.

Holiday food

It’s time to break up with that tin of peppermint bark, the container of homemade cranberry sauce or the turkey carcass that hasn’t and will never be turned into stock. Use it up now or throw it out.

Ingredients from 2025 that are languishing

If you bought an ingredient for a dish you made once and will never make again, or that you simply ended up not liking, this is the time to remove it from your life.

That one serving platter that exists to cause you trouble

Not everyone will have one of these, but those of you who do know the exact platter in question: It’s too heavy, too wide or too weirdly shaped, and it never quite works for anything other than getting in your way. Make 2025 the last year you deal with this diva! Donate or sell it if you can, and if it’s an heirloom or similarly significant, pass it along to a family member.

Reusable bags

These things proliferate in the night, and we all have too many of them. If you’ve still got a stack of Trader Joe’s bags with receipts from 2024 in them, a stash of plastic bags spilling out of other plastic bags or shopping bags from stores you haven’t shopped at in years, it’s a sign that you do not actually reuse those reusable bags you keep hanging on to.

Automotive detritus

Does your car need to be cleaned out? Grab a trash bag and spend five minutes purging. It will have an almost-immediate positive effect on your life.

Broken, duplicate or unused cooking utensils and small appliances

This one is especially well-suited to people who plan to make changes to their diets or undertake new cooking or baking endeavors in the new year. Donating or selling utensils and small appliances in January is ideal because for every person who vowed to eat less ice cream in the new year, there’s also a person who is making 2026 their year of ice cream artistry.

Anything you don’t like the smell of

Whether it’s a candle, a body wash, a countertop spray or a perfume, the experience of feeling stuck with a scented item that you hate the smell of is so relatable. Free yourself from those stinking shackles! Admit it was a mistake, and cast it off.

Promotional items and/or freebies you got in 2025

Water bottles, koozies, T-shirts, key chains, notepads — promotional items take many forms, and they’re free, which makes it easy to say, “Eh, it was free. Might as well keep it.” But if you didn’t pay for it and you don’t use it, you owe it nothing and it owes nothing to you. Toss, recycle or donate.

Cleaning products you don’t use

A small collection of cleaning agents are all you need to keep a clean home. Stocking a huge array of cleaning products is counterproductive. They’ll get in your way and make it harder for you to keep your home clean! Unwanted cleaning products, including ones that have been opened, are also super donate-able.

Old slippers

Alas, old slippers are not super donate-able, which can make them oddly hard to part with. But when you replace old slippers with new ones, it is time to say goodbye to your old friends. Beware of the role reassignment trap, here: Are those house slippers you bought in 2019 really going to serve as your new outdoor shoe?

Old dog leashes and collars

Leashes and collars are to our dogs as slippers are to us, which is funny to think about! Hopefully, bringing a bit of humor to the purge party will make it easier to admit that those old leashes and collars will not be used again.

Broken luggage

If you returned from holiday travels with broken luggage, repair it or toss it. Deal with it now; it won’t become less broken in the future.

Hair accessories, products or tools from two hair styles ago

Maybe it’s a bottle of purple conditioner from your short-lived platinum blond era or the round brush you bought when you decided to cut bangs or those clips you bought when you admitted the bangs were a mistake and set about growing them out. If it’s intended for a hairstyle you no longer have, it’s clutter that’s taking up valuable bathroom storage space.

Too many hangers

A common reason people struggle to keep their clothes organized is that their closets are simply too jammed up to be functional. Free up some space by paring down your spare hanger collection.

Rags, used sponges and old toothbrushes

All the stuff you reassigned as cleaning tools, if you’re not actually using them, then you’re just storing old, gross trash with your cleaning supplies.

Clothes you didn’t mend in 2025

This can feel like a bummer, because it requires admitting that you meant to do something, and didn’t, and that you’re unlikely to do it in the future. Use January’s “fresh start” energy to make a clean break from those unmended clothes, instead of clinging to a past you’ve grown out of.

Broken electronics you didn’t fix in 2025

Ditto broken electronics.

Empty boxes

Empty boxes — shipping boxes, product boxes, even unused storage containers — take up space and get in the way. Remove them from your orbit! Put the broken electronics and unmended clothes and gross old toothbrushes in them and get rid of all of it at once!

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How does a global community provide for the needs of its citizens without destroying the planet? That’s the crux of “Anthropause: The Beauty of Degrowth,” a new book out this month.

In the early days of the Covid-19 pandemic, society shut down for a few months. As humans stayed inside, animals returned to their old habitats and pollution eased as industry slowed.

Retired researcher—and new metro Detroit resident—Stan Cox looks at how that “anthropause” could be a preview of the necessary societal changes to save lives and the planet.

He spoke with All Things Considered – Detroit host Russ McNamara last month. Click on the media player to listen or read selected transcripts below.

Listen: New book examines equitable degrowth as necessary to combat climate change

Russ McNamara, WDET: Why did you write this book?

Stan Cox, Author: The main point I’m making in the book is imagining that we as a society, if we were to rapidly phase out fossil fuels and get by just on the energy that could be generated other ways; and if we stopped plundering the earth for minerals and cutting down forest and causing ecological damage; and we had less energy and materials, and had to allocate them carefully: people know that’s going to mean sacrifice. What am I going to have to give up and so forth?

And what I’m saying in the book is okay, yeah, there are certain things, obviously that will have to be given up. But let’s consider all of the dangers and nuisances, terrible stuff that we put up with an advanced industrial society that has all this energy and materials running through it.

We would be saying goodbye to a lot of those harms and ills by simply not doing a lot of the stuff that requires so much energy input. So the rest of the book, then, is going through specific technologies and activities and so forth that are really harmful to people and the environment, of course, that we would not have the fuel to undertake them, or we would be using resources for meeting people’s basic needs, and we wouldn’t be spending a lot of energy on these other things.

RM: You discuss this and I’m reminded of data centers to run artificial intelligence. People certainly don’t seem to want them and definitely don’t want these in their backyard because there is this concern about the high cost of electricity, and the amount of groundwater that is needed.

SC: That’s absolutely right. One of the big reasons these communities don’t want them is that they create this horrific noise at very high decibel levels and low low frequency noise, which is especially dangerous to human health. When I started writing the book, there wasn’t as much being said about A.I. and the data centers at that time, so I did eventually incorporated them, but the beginning of the second chapter is about noise pollution and and I just used it. It’s seemingly a very small thing, but it really brings out other issues. The leaf blower, especially the gas powered leaf blower, also produces this low frequency and very high volume sound—about eight times the decibel level that the World Health Organization says is safe – and they’re producing a wind about the speed of an EF five tornado. The low frequency sound can travel like three football fields. It’s still above the safe limit.

RM: So what are the societal impacts? Let’s say we start degrowth right now. What are the benefits?

SC: We can’t go on like we’re on the trajectory that we’re on now, because. A degrowth is going to happen. Either a chaotic, brutal degrowth where it’s a Mad Max kind of future, because we’ve tried to force growth to continue and have destroyed ecosystems

Or we can have a planned, rational degrowth that ensures that there’s enough for everybody and that we’re not causing ecological collapse. But there’s no way that growth can continue at this rate.

Sometime in the past three years, we passed a milestone. The quantity of human made stuff—that is everything that human society has manufactured or built or produced—if you weigh all of it up, the mass of all of that exceeds the total mass of all living things on Earth, all plants, animals, microbes, et cetera, and that quantity of stuff being produced is is doubling every 20 years. And clearly that can’t go on.

Herb Stein, an economist from the 70s or 80s was kind of the Yogi Berra of economists. He had a line: “if something can’t go on forever, it won’t” and that’s where growth cannot go on forever. So we have to pull back, create what I called in the book an “anthropause” of our own, and try to have a rational, safe and just reduction in the amount of economic activity for the good of everybody.

 

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Safety continues to improve in Detroit. 

Recent numbers suggest that homicides fell well below 200 last year. That was the first time that happened in six decades. 

There are a number of things that are given credit for the decline. Community violence interventionists who are preventing harm, and police officers that focus on de-escalation and complete their homicide investigations. It can also be attributed to increased surveillance with things like Project Green Light. 

Now, Mayor Mary Sheffield is creating an Office of Neighborhood & Community Safety, which will focus on mental health issues, after-school programs and resident access to jobs to further increase safety. 

What exactly will the office do? And why is a holistic approach needed to increase resident safety?

Shantay Jackson is the Director of the National Offices of Violence Prevention Network at the National Institute for Criminal Justice Reform, which will help establish Detroit’s office. She spoke with The Metro‘s Sam Corey.

 

 

Listen to The Metro weekdays from 10 a.m. to noon ET on 101.9 FM and streaming on demand.

Subscribe to The Metro on Apple Podcasts, Spotify, NPR.org or wherever you get your podcasts.

Support local journalism.

WDET strives to cover what’s happening in your community. As a public media institution, we maintain our ability to explore the music and culture of our region through independent support from readers like you. If you value WDET as your source of news, music and conversation, please make a gift today.

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The post The Metro: Detroit’s new neighborhood safety office will lead with community residents appeared first on WDET 101.9 FM.

Being a mom can mean a lot of different things. For people experiencing pregnancy, the whole ordeal can be stressful, daunting and quite scary.

And without the proper tools and resources, moms are often at risk after giving birth during the postpartum period, which can lead to dangerous outcomes for mom and baby. 

ROSE or The Reach Out, Stay Strong, Essentials program is for birthing parents. It provides pregnant people with the skills and information they need to have better outcomes after giving birth. 

Dr. Jennifer E. Johnson is the founding Chair of the Charles Stewart Mott Department of Public Health at Michigan State University. Dr. Johnson is a University Distinguished Professor, and the first C. S. Mott Endowed Professor of Public Health at MSU. 

 

Listen to The Metro weekdays from 10 a.m. to noon ET on 101.9 FM and streaming on demand.

Subscribe to The Metro on Apple Podcasts, Spotify, NPR.org or wherever you get your podcasts.

Support local journalism.

WDET strives to cover what’s happening in your community. As a public media institution, we maintain our ability to explore the music and culture of our region through independent support from readers like you. If you value WDET as your source of news, music and conversation, please make a gift today.

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For more than half a century, the American environmental movement has struck a familiar rhythm: alarm, action, and industry backlash.

The first Earth Day in 1970 helped launch the modern movement, and by the end of that year, the Environmental Protection Agency was born. It was a promise that government had a crucial role to play, that it could protect our air and water from industry polluters.

Over the decades, that promise has ebbed and flowed: environmental rules were expanded under presidents from both parties, then pared back under others, only to be reinforced again as new science and public pressure emerged.

Critics — including historian Douglas Brinkley and former EPA administrators from both parties — argue the rollback push is an attempt to turn back decades of federal environmental protections.

Meanwhile, a striking silence is showing up in a place with massive moral reach. A new large-scale study of more than 700,000 Catholic parish sermons finds that climate change is rarely mentioned, even after the late Pope Francis issued some of the strongest language on climate change written by a religious leader.

Harvard historian of science Naomi Oreskes led that research. She joined The Metro’s Robyn Vincent to discuss the price of that silence.

 

Listen to The Metro weekdays from 10 a.m. to noon ET on 101.9 FM and streaming on demand.

Subscribe to The Metro on Apple Podcasts, Spotify, NPR.org or wherever you get your podcasts.

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Michigan’s schools are increasingly tasked with more than teaching.

They are expected to raise reading and math scores, address rising mental health needs, manage technology and discipline, and serve as safe, stable places for families under stress. In some communities, they’re also absorbing fear sparked by immigration enforcement actions. That includes the detention of Detroit students seeking asylum.

Academically, the picture is mixed. On national exams, Michigan’s scores remain close to the U.S. average. But since the pandemic, other states have improved more quickly, especially in early reading. Michigan has moved more slowly, and over time, that difference adds up.

Meanwhile, chronic absenteeism is improving, but many students, especially in Detroit, still miss school regularly.

The state has increased funding and continued free school meals. Educators say those steps help. They also say long-standing challenges persist in special education, staffing, and student support.

This is the landscape facing Michigan’s new top education official.

Dr. Glenn Maleyko was sworn in last month as State Superintendent of Public Instruction. He steps into the new role after nearly a decade leading Dearborn Public Schools. He has identified literacy as his priority and launched a statewide listening tour.

The Metro’s Robyn Vincent sat down with Maleyko to learn how he plans to lead a system being asked to do more than it was designed to handle.

 

Listen to The Metro weekdays from 10 a.m. to noon ET on 101.9 FM and streaming on demand.

Subscribe to The Metro on Apple Podcasts, Spotify, NPR.org or wherever you get your podcasts.

Trusted, accurate, up-to-date.

WDET strives to make our journalism accessible to everyone. As a public media institution, we maintain our journalistic integrity through independent support from readers like you. If you value WDET as your source of news, music and conversation, please make a gift today.

Donate today »

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By Anne Snabes, asnabes@detroitnews.com

When he was to gather with family at his grandparents’ house for Christmas dinner this year, Edward Constantineau of Sterling Heights planned to be surrounded by the people who pushed him to fight to recover from the hardest thing he’s ever faced in his young life, a hurdle he’s still working to overcome.

Constantineau was just 19, working out at his local gym in March of this year, when he suffered the unimaginable for a teenager: a stroke. He underwent immediate surgery on a bleed in his brain and later went through six weeks of inpatient rehab at a facility in Detroit, learning how to move again, talk and regain fine motor skills.

But through it all, Constantineau said his biggest motivator as he’s gone through rehab and fought to recover has been “my family and friends.”

“My family was always there,” said Constantineau, now 20. “I mean, my mom never left my side.”

Henry Ford Health officials say Constantineau’s story highlights the importance of early detection and rapid treatment of strokes, only about 10-15% of which occur in people younger than 50. Constantineau’s stroke was caused by a rare condition called arteriovenous malformation, in which arteries and veins mesh together without capillaries connecting them, said his neurologist, Dr. Mohammed Rehman.

Constantineau didn’t know he had the malformation at the time, but it ruptured.

Rehman said that in Edward’s case, the gym receptionist called 911 “right away.”

“If you ever have a neurological deficit … or you think something is going on and something is off, don’t hesitate” to call 911, Rehman said.

Looking back on her son’s ordeal and how it started, Stephanie Constantineau, Edward’s mom, thinks he “saved his own life” by asking for help when he was in the gym and felt his arm weaken. He was the one who asked the receptionist to call 911.

“I definitely believe there was a stronger force with him, watching over him,” she said. “I don’t know, a guardian angel, if you will.”

And Rehman believes Constantineau’s steadfast support system and drive to get better have played a role in his “remarkable” recovery.

“That’s a very rare thing I see, because at his age, when you face something like this, it’s very tough to cope with a lot of things,” Rehman said. “And I could tell, Eddie was driven.”

The stroke

Constantineau, a 2023 graduate of Henry Ford II High School, where he played varsity baseball, said he doesn’t have any memory of the stroke, but he has been told that it started soon after he got to his gym, The Edge Fitness Clubs, on March 14.

As he was doing lat pulldowns, an exercise that involves pulling down a weighted bar attached to a gym machine while seated, he felt his left arm go weak. He asked the gym’s receptionist to call 911; she also called his parents.

Paramedics brought Constantineau to Henry Ford Macomb Hospital in Clinton Township, where they quickly performed surgery.

The next couple of days were “kind of a blur,” Stephanie Constantineau recalled. She describes them as “emotional” and “hard.” She felt helpless as a parent.

“I think the first 48 to 72 hours were really touch and go with him, like it was just like getting him through those first three days to see how, if he was going to recover from the surgeries,” she said.

A rare medical condition

Rehman, a neuroendovascular physician at Henry Ford Health, said most strokes are caused by a blockage of a blood vessel, while others are caused by a bleed in the brain. He said one of the rare causes of a bleed in the brain is an arteriovenous malformation.

Capillaries connect arteries to veins in the body. An arteriovenous malformation (AVM) is a jumble of arteries and veins with no capillaries between them, according to the Cleveland Clinic. The incidence of the condition is around 1 in 100,000 people. The malformations typically occur in the brain, and they’re usually present from birth, according to Henry Ford Health.

Rehman said AVMs often present in young people, and bleeding most commonly occurs between the ages of 10 and 40. He said the Henry Ford Health system sees three to five ruptured arteriovenous malformations a year, and it also sees around 40 to 50 people a year whose malformations haven’t ruptured. AVMs cause symptoms such as severe headaches, seizures or weakness as damage builds, he said.

Dr. Mark Goldberger, a neurosurgeon, did the initial surgery on Constantineau, removing a significant amount of blood from the brain. In the following weeks, his doctors did a few angiograms, or blood vessel tests. In the second angiogram, they discovered the AVM, Stephanie Constantineau said.

Rehman said it took Constantineau at least five to seven days to wake up from the initial surgery ― he was in a coma. Overall, he spent 27 days in the intensive care unit.

“It’s heartbreaking to see your son go through something like this and not know how it’s gonna end up,” Stephanie Constantineau said, tearfully. “Like I say, ‘You just put all your faith in God and the doctors, and just trust that everything’s going to be OK.’ But it’s hard, because we have two other kids.”

She said she never left her son’s side. She spent every night at the hospital and would return home briefly to shower.

The therapy process

After leaving the hospital, Constantineau spent 43 days in inpatient rehabilitation. He said the beginning of the recovery process was “the toughest.”

“I was at a stage where I couldn’t even sit up straight,” he said, referring to when he was in the hospital and the early days of rehab. “I had lost all my muscle and was just sitting in a wheelchair, which was tough every single day. I just felt like stuck in a place where I couldn’t even move.”

He said therapy was “intense” and “very constant,” occurring five or more days a week. He underwent occupational, physical and speech therapy, the latter of which was necessary because he had “no voice after coming off of intubation,” he said.

Constantineau said fine motor skills were “the most frustrating” part of therapy, and he’s still working on it.

“He still doesn’t have, like, mobility of his left hand, like the wrist and fingers, yet,” said Stephanie Constantineau, adding that the recovery takes “a good 18 months.”

“I mean, we haven’t lost hope,” she said. “He works hard every single day.”

At home, Constantineau continues to do therapy each day, he said. In his family’s basement, he does exercises his therapist has recommended and rides on a stationary bike.

“I’ve been trying to adjust to getting back into my regular life by hanging out with friends” and taking an online class at Macomb Community College this fall, he said.

The signs of stroke

Rehman said in an email that strokes can affect anyone at any age, though the likelihood of it increases with age. He said about 10-15% of strokes occur in people under 50. He urged everyone, including young people, to be aware of the signs of a stroke and shared the acronym F.A.S.T. It stands for “Facial drooping, Arm weakness, Slurred speech, Time to call 911.”

He said that if you or anyone around you experiences these symptoms, you should seek medical attention immediately.

“The fact that Eddie sought help immediately when he began experiencing symptoms is incredibly important,” he said. “That allowed 911 to be called and emergency care to be administered quickly. When a stroke occurs, every second counts. The faster a person seeks treatment, the better their outcome.”

His plans for the future

In January, Constantineau will resume in-person classes at MCC, where he is studying exercise science. He plans to re-do the classes he was taking when the stroke occurred earlier this year.

After finishing his associate’s degree, he plans to transfer to Oakland University and is planning to go into health care, either as a nurse or a physician assistant. Constantineau said he originally wanted to go into health care because of his interest in sports, but after everything he’s experienced since his stroke, it has reinforced his decision to go into the field.

Looking back on his experience, Constantineau said the early days of his recovery were “rough” — “I think I was stuck in that ‘why me?’ mentality” — but is now “very confident” with the progress he has made. But he also knows that recovery takes time.

“I think that’s the tough part … just waiting all that time, but … I’m definitely optimistic for the future,” he said.

By DEVI SHASTRI, Associated Press

The new year is a time when many try to start new good habits and commit to improving health and wellness.

But resolutions, lofty as they may be, can turn daunting quickly with all the advice and sometimes contradicting information coming at you from news reports, advertisers, influencers, friends and even politicians.

But they don’t have to be.

This year, The Associated Press got the downlow on all manner of health and wellness claims and fads. The good news is that the experts mostly say to keep it simple.

As 2026 arrives, here’s what you can skip, what you should pay attention to and how to get credible information when you are inevitably faced with more confusing claims next year.

Protein and fiber are important, but you probably don’t need to pay more

When it comes to your diet, experts say most people can skip the upcharge. If you’re eating enough, you’re probably getting enough protein and don’t need products that promise some big boost.

And it’s true that most people could use more fiber in their diets. But, please, ditch the “fiber-maxxing” trend. Instead, eat whole foods such as fruits, vegetables, beans and whole grains.

A good skin care routine is not expensive or complicated

That 20-step skin care routine and $200 serum some TikToker sold you on? Dermatologists say you really don’t need it. Stay away from the beef tallow and slather on a good sunscreen instead (yes, even if you have darker skin ), they say.

And the same rule for simplicity applies to that hourlong “everything shower.” The best showers are simple and short, dermatologists say, no “double cleansing” required.

There are many simple ways to get that workout in

If the gym and all its equipment feel intimidating, you can drop the illusion that a good workout requires either. This year, the comeback of calisthenics put the focus back on no frills, bodyweight workouts you can do in the comfort of home. Research shows calisthenics helps with muscle strength and aerobic conditioning. You may eventually need weightlifting or other equipment, but it is a great place to start to build consistency and confidence.

Be wary of wellness fads and treatments — they are often too good to be true

Even if you imbibe too much this New Year’s Eve, doctors say you can do without “IV therapy” which have vitamins you can get more easily and cheaper in pill form — if you even need more, which is unlikely if you have a balanced diet. You’re pretty much just paying for “expensive urine,” one doctor said.

Same for “wellness” focused products like microbiome testing kits that generate information that doctors can’t actually act on. And if you don’t have diabetes, there’s scant evidence that you need a continuous glucose monitor.

To improve your health, go back to the basics

The idea of a panacea pill, product or routine can be enticing. But science already knows a lot about how to improve mental and physical health, and they are tried and true:

1. Whether you’re in the city or the country — walk more. Research shows walking is great for physical and mental health. It’s so good for you, doctors are literally prescribing time in the outdoors to their patients.

2. Take steps to get certain health metrics under control, like high blood pressure, which often goes undiagnosed and is known to cause a range of health problems down the road. Prioritize getting enough sleep, and make sure your family does too. Don’t just eat right — eat slower.

3. Give your mind some care too. Set better boundaries with your technology and regain and retrain your attention span. Build out your social networks and invest in all forms of love for the people around you.

These lifestyle changes don’t just make you feel better in the moment. Research shows they impact your life for years to come, by lowering the risk of dementia and many other health issues.

Don’t know who to trust? Start with your doctor

It can be tough to know who to listen to about your health, faced with compelling personal stories on social media from people who swear something worked from them, or clever marketing and advertising from companies that scare you or promise an easy fix.

Doubts have been raised this year about established medicine, including the safety of food dyes, fluoride dental treatments,hepatitis B shot for newborns, and hormone therapies for menopause.

While the medical system is not perfect, your doctor remains the best person to talk to about prevention, health concerns and potential treatments.

If you can’t get to a human doctor and turn to Dr. Google instead, be sure to follow these tips and never use it to diagnose yourself. When you do get that doctor’s appointment, you can make the most of it by bringing a list of written questions — and don’t hesitate to ask for any clarification you need.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.

By ALI SWENSON The Associated Press

NEW YORK (AP) — Enhanced tax credits that have helped reduce the cost of health insurance for the vast majority of Affordable Care Act enrollees expired overnight, cementing higher health costs for millions of Americans at the start of the new year.

Democrats forced a 43-day government shutdown over the issue. Moderate Republicans called for a solution to save their 2026 political aspirations. President Donald Trump floated a way out, only to back off after conservative backlash.

In the end, no one’s efforts were enough to save the subsidies before their expiration date. A House vote expected in January could offer another chance, but success is far from guaranteed.

The change affects a diverse cross-section of Americans who don’t get their health insurance from an employer and don’t qualify for Medicaid or Medicare — a group that includes many self-employed workers, small business owners, farmers and ranchers.

It comes at the start of a high-stakes midterm election year, with affordability — including the cost of health care — topping the list of voters’ concerns.

“It really bothers me that the middle class has moved from a squeeze to a full suffocation, and they continue to just pile on and leave it up to us,” said 37-year-old single mom Katelin Provost, whose health care costs are set to jump. “I’m incredibly disappointed that there hasn’t been more action.”

Some families grapple with insurance costs that are doubling, tripling or more

The expired subsidies were first given to Affordable Care Act enrollees in 2021 as a temporary measure to help Americans get through the COVID-19 pandemic. Democrats in power at the time extended them, moving the expiration date to the start of 2026.

With the expanded subsidies, some lower-income enrollees received health care with no premiums, and high earners paid no more than 8.5% of their income. Eligibility for middle-class earners was also expanded.

On average, the more than 20 million subsidized enrollees in the Affordable Care Act program are seeing their premium costs rise by 114% in 2026, according to an analysis by the health care research nonprofit KFF.

Those surging prices come alongside an overall increase in health costs in the U.S., which are further driving up out-of-pocket costs in many plans.

Some enrollees, like Salt Lake City freelance filmmaker and adjunct professor Stan Clawson, have absorbed the extra expense. Clawson said he was paying just under $350 a month for his premiums last year, a number that will jump to nearly $500 a month this year. It’s a strain for the 49-year-old but one he’s willing to take on because he needs health insurance as someone who lives with paralysis from a spinal cord injury.

Others, like Provost, are dealing with steeper hikes. The social worker’s monthly premium payment is increasing from $85 a month to nearly $750.

Effects on enrollment remain to be seen

Health analysts have predicted the expiration of the subsidies will drive many of the 24 million total Affordable Care Act enrollees — especially younger and healthier Americans — to forgo health insurance coverage altogether.

Over time, that could make the program more expensive for the older, sicker population that remains.

An analysis conducted last September by the Urban Institute and Commonwealth Fund projected the higher premiums from expiring subsidies would prompt some 4.8 million Americans to drop coverage in 2026.

But with the window to select and change plans still ongoing until Jan. 15 in most states, the final effect on enrollment is yet to be determined.

Provost, the single mother, said she is holding out hope that Congress finds a way to revive the subsidies early in the year — but if not, she’ll drop herself off the insurance and keep it only for her four-year-old daughter. She can’t afford to pay for both of their coverage at the current price.

Months of discussion, but no relief yet

Last year, after Republicans cut more than $1 trillion in federal health care and food assistance with Trump’s big tax and spending cuts bill, Democrats repeatedly called for the subsidies to be extended. But while some Republicans in power acknowledged the issue needed to be addressed, they refused to put it to a vote until late in the year.

In December, the Senate rejected two partisan health care bills — a Democratic pitch to extend the subsidies for three more years and a Republican alternative that would instead provide Americans with health savings accounts.

In the House, four centrist Republicans broke with GOP leadership and joined forces with Democrats to force a vote that could come as soon as January on a three-year extension of the tax credits. But with the Senate already having rejected such a plan, it’s unclear whether it could get enough momentum to pass.

Meanwhile, Americans whose premiums are skyrocketing say lawmakers don’t understand what it’s really like to struggle to get by as health costs ratchet up with no relief.

Many say they want the subsidies restored alongside broader reforms to make health care more affordable for all Americans.

“Both Republicans and Democrats have been saying for years, oh, we need to fix it. Then do it,” said Chad Bruns, a 58-year-old Affordable Care Act enrollee in Wisconsin. “They need to get to the root cause, and no political party ever does that.”

By Peter WhoriskeyThe Washington Post

JACKSON HOLE, Wyo. – Like millions of other Americans, Stacy Newton turns to Healthcare.gov to shop for health insurance for her family. The Affordable Care Act website, according to the government, is where consumers are supposed to find “a menu of health insurance plans.”

But for the Newtons and many others in the country, next year’s menu is severely limited: There is only one company offering ACA plans here – and costs have risen steeply.

To continue health coverage for themselves and their two teenage children, the Newtons would have to pay an annual premium of $43,000 – about a third of their gross income. It is the price of the cheapest plan available to the family from Blue Cross Blue Shield of Wyoming, the only ACA insurer left in Teton County.

This year, millions of American families that have relied on ACA, popularly known as Obamacare, are being squeezed on multiple sides: Premiums are rising, the covid-era subsidies that helped pay for those policies are shrinking, and there are fewer choices with insurers pulling out of some markets.

The squeeze here is a symptom of broader trouble in American health care. In western Wyoming and other regions, the expected rollback of enhanced subsidies has destabilized the economics of Obamacare, pushing some insurers to retreat from the government-supported market because it won’t be profitable.

That is leaving consumers such as the Newtons with little choice but to buy a pricey, unsubsidized policy from a local monopoly.

Next year, the number of counties with only one company providing Obamacare will jump from 72 to 146, according the Robert Wood Johnson Foundation. That number is expected to rise further if, as appears likely, Congress fails to renew the enhanced subsidies.

Newton and her husband, Derek, each run a small business – she is an independent sales representative, and he outfits vans – and like many entrepreneurs, they have relied on the ACA for health insurance. But this year, the price of their policy rose 34 percent, and the federal subsidy that helped them pay for it is due to go away. At the same time, they know they will need medical care: Last year, Newton, 51, was diagnosed with chronic leukemia.

“It’s terrifying,” she said. “We’re not rich, we’re not poor. We’re a standard, middle-class family, and somehow now I can’t afford health insurance.”

This year, the enhanced subsidies that helped middle-income people afford Obamacare plans have been stuck in partisan congressional deadlock. The subsidies expire Dec. 31, and Republicans, who hold the majority, have opposed extending them.

Anticipating that sticker shock will induce healthy people to drop out of insurance and saddle health plans with a higher proportion of the sickest, costliest patients, insurers say they must dramatically raise ACA prices or pull out of Obamacare marketplaces altogether.

Without the enhanced subsidies, “I would expect more insurers to retreat, to exit,” said Katherine Hempstead, a senior policy officer at the Robert Wood Johnson Foundation. “People will see less choice and higher prices.”

According to economic studies conducted in 2017 and 2018, another turbulent period when Obamacare insurers faced losses and political uncertainty, prices rose between 30 and 50 percent when an area was reduced to only one ACA insurer.

The problem here in Teton County began in August when the only other insurer providing ACA coverage, Mountain Health Co-op, announced it was pulling out, citing the looming expiration of the enhanced subsidies. Of the roughly 46,000 people on Obamacare in Wyoming, about 11,000 are expected to drop coverage, according to insurers.

“The basic problem with reducing the subsidies is that healthier people say ‘we can’t afford insurance’ and drop out, while the sicker population are, like, ‘Oh, my God, I still need it,’” said Alexander Muromcew, a board member of the Mountain Health Co-op. “As an insurer, you end up with a smaller and higher-risk membership, which is not sustainable.”

Muromcew said competition had been good for consumers, noting that when Mountain Health entered the market here a few years ago, Blue Cross Blue Shield dropped its prices. Now, as a monopoly, he said, Blue Cross Blue Shield has more power to dictate prices.

“Without competition, I worry that it’ll be easier for Blue Cross Blue Shield to raise rates even further,” Muromcew said.

Diane Gore, president and chief executive of Blue Cross Blue Shield of Wyoming, said she understands the frustration of people getting hit with rising premiums and lowered subsidies.

“I get it, I completely get it,” Gore said.

The company says its prices are the same across most of Wyoming, regardless of whether there is a competitor. Gore attributed this year’s price hikes, which she said were 25 percent on average, to the expectation that the remaining Obamacare customers will be sicker, and to the rising cost of medical care in rural areas, where health care providers are scarce and competition is often limited. Of every premium dollar the company collected last year, she said, 95 cents went to direct medical care.

Insurance companies don’t always find Obamacare markets profitable. Aetna, one of the largest insurance companies, announced earlier this year that it was dropping ACA coverage in 11 of 15 states. The move affected about a million Obamacare customers.

“I understand that there is rhetoric from the Beltway that the insurance companies are getting rich off of Obamacare,” Gore said. “But that’s not this insurer in Wyoming.”

‘Clearly, the system is broken’

Many people in this resort town are seasonal workers, self-employed or small-business entrepreneurs. Lacking employer insurance plans, they have come to rely on Obamacare. Among them, the anxiety is widespread.

“Clearly, the system is broken,” said Heather Huhn, an insurance broker in Jackson.

On her desk, she has a stack of files with the applications for about 30 families that she calls the “Hold Tight” pile. They are mainly people who have ongoing medical needs, such as chronic conditions or expensive prescriptions, and can’t afford to pay for health insurance at the current costs. For weeks, she said, they have been desperately waiting to see whether the government will extend the enhanced subsidies that began during the pandemic.

“They sit across from my desk and say, ‘I just don’t know what to do,’” Huhn said. “I tell them not to have a mental breakdown just yet. People are having to suffer because the government can’t figure out how to fix it.”

Sophia Schwartz, a professional skier and health care administrator here, senses similar apprehension. For years, she has been inviting groups of “ski friends,” many of whom have irregular jobs, over for dinner to counsel them on how to get health insurance.

“This was the scariest year I’ve ever done it,” said Schwartz, a former member of the U.S. ski team and now a big-mountain skier. “People came to me in pure panic.”

Considering ‘BearCare’ and other options

In desperation, many are turning to stopgap measures.

Some, especially skiers, were looking at policies at a company called Spot Insurance that cover reimbursement of medical bills incurred after accidents on the slopes. Others were looking at “healthshare” groups in which members contribute monthly to cover each other’s eligible medical bills; among the drawbacks of these programs is that elective surgeries and nonemergency treatments might not be covered.

And some were considering “short-term” insurance policies. Those are closer to conventional health insurance, but those insurers might reject applicants with medical conditions such as diabetes, heart disease or cancer.

With so many in Wyoming searching for answers, even the state is jumping in. State officials have proposed “a major medical plan” they have called “BearCare.” The policies would, at “a significantly lower price,” cover emergency situations such as “being attacked by a bear” and other more common medical catastrophes. It would not cover ongoing or chronic medical needs.

Some of those looking for conventional health insurance say the state proposal is woefully inadequate.

“I don’t worry about being bitten by a bear, I worry about getting cancer,” said Margie Lynch, 58, an energy efficiency consultant based here. For the cheapest Obamacare plan, she would have to pay $1,585 a month. Its benefits would not kick in until she paid a deductible of $10,600.

“The cost of the premium is almost as much as my mortgage,” Lynch said. “I’m lucky enough to be able to pay for it if I have to. But there are so many people out there who won’t be able to.”

Newton, Lynch and others here have shared their concerns with Wyoming’s representatives in Congress: Sen. John Barrasso, Sen. Cynthia Lummis and Rep. Harriet Hageman. All three Republican lawmakers have opposed Obamacare and criticized Democrats, who have pushed to extend the enhanced subsidies.

“Stacy’s story and experience is one of the many heartbreaking examples of how Obamacare has failed families across Wyoming,” a statement from Barrasso said. “Instead of working with Republicans to make health care more affordable for all Americans, Democrats would rather use more taxpayer dollars to bail out Obamacare and hide its failures.”

A spokesman for Lummis said, “The health care problem Americans are facing is a direct result of the Democrats’ failed Affordable Care Act – Sen. Lummis had the foresight to oppose this misguided legislation from day one.”

A spokesperson for Hageman said in a statement that “Rep. Hageman knows there are many people struggling with the weight of medical expenses, and the catastrophic failure of Obamacare is making it far worse.”

The squeeze

For years, Obamacare had worked well for the Newtons.

In 2017, when the couple were starting their businesses, their income was low – about $56,000. The price of their policy was $1,585 a month, but the standard ACA subsidy covered most of that, and the couple had to come up with only $332 monthly.

Since then, however, the prices of the premiums have risen steadily, and now, because of the expected subsidy reductions, they would no longer qualify for government help. They would have to pay full price – $3,573 monthly for the cheapest option. Even at $43,000 a year, the plan carries a $21,200 deductible, according to the paperwork Stacy Newton showed The Washington Post.

This month, the couple struggled with whether to pay that to Blue Cross Blue Shield of Wyoming, go without health insurance or find some other stopgap option. Newton was getting notices that said, in bold red lettering: “Important – You’re about to end (terminate) this coverage. If any of the people above get health care services or supplies after 12/31/2025, they’ll have to pay full cost.”

Eventually, Newton knows, she will need leukemia treatment. She’s just not sure when.

“If my leukemia acts up, I’m up a creek,” she said this month. “I just don’t have a solution yet.”

On Monday, she sent a text.

“I just officially canceled my ACA marketplace insurance for 2026,” she wrote. “How on Earth is this going to unfold for millions of people in America?

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By Maria Salette Ontiveros, The Dallas Morning News

DALLAS — A new version of the common flu is spreading globally, and health officials are monitoring this evolving strain of influenza A(H3N3) Subclade K, which has been increasingly detected worldwide.

Seasonal influenza activity has increased globally in recent months, with influenza A viruses accounting for the majority of detections, according to the World Health Organization.

Health officials are closely monitoring a growing subgroup of influenza A(H3N2) viruses known as J.2.4.1, also referred to as Subclade K.

The WHO says detections of this subclade have risen rapidly since August 2025 based on genetic sequence data shared through the global GISAID database.

Current epidemiological data do not indicate increased disease severity associated with subclade K, the WHO says, though its spread reflects the continued evolution of seasonal influenza viruses.

What is subclade K?

Subclade K is a genetically distinct subgroup of influenza A(H3N2) viruses, according to the WHO.

These viruses have drifted genetically from related J.2.4 viruses and carry several amino acid changes in the haemagglutinin protein, which plays a key role in the virus’s attachment to human cells.

Influenza viruses commonly undergo such changes over time. Global surveillance tracks these shifts to assess potential impacts on transmission, severity, and vaccine effectiveness.

Where is subclade K circulating?

The WHO reports that subclade K viruses were first detected at increased levels beginning in August 2025, particularly in Australia and New Zealand.

Since then, the viruses have been identified in more than 34 countries over the past six months, including the U.S.

Detections are increasing in many regions of the world, except so far in South America, according to the WHO.

What is happening in America?

Data from the U.S. Centers for Disease Control and Prevention show that influenza activity in North America remains relatively low but is increasing, driven mainly by detections of influenza A viruses.

During the 2025 southern hemisphere influenza season in the Americas, transmission exceeded the seasonal threshold in mid-March and mainly remained at low to moderate levels, the CDC says.

The CDC reports a predominance of influenza A(H3N2) in both the United States and Canada, with growing detections of the A(H3N2) subclade K.

Are symptoms different?

The WHO says there is no evidence that infections caused by subclade K produce symptoms that differ from or are more severe than those caused by other seasonal influenza A(H3N2) viruses.

Seasonal influenza symptoms typically include fever, cough, sore throat, runny or stuffy nose, muscle or body aches, headache and fatigue. Severity can vary based on age, underlying health conditions and immune status.

Do vaccines still protect?

Early estimates cited by the WHO suggest that seasonal influenza vaccines continue to protect against severe illness and hospitalization in both children and adults.

While effectiveness against symptomatic infection may vary from season to season, health officials say vaccination remains one of the most effective public health measures, particularly for people at higher risk of influenza complications and their caregivers.

Even when circulating viruses differ genetically from vaccine strains, vaccines may still reduce the risk of severe outcomes, the WHO says.

What happens next?

The WHO says it continues to monitor global influenza activity and viral evolution, while supporting countries in surveillance efforts and updating guidance as new data emerge.

Health officials note that changes in circulating influenza viruses are expected each season and are routinely assessed through international monitoring systems.

©2025 The Dallas Morning News. Distributed by Tribune Content Agency, LLC.

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By GEOFF MULVIHILL

Nebraska will become the first state to implement new work requirements for some people with Medicaid health insurance under a law President Donald Trump signed last year.

Gov. Jim Pillen, a Republican, announced Wednesday that the requirement would take effect in the state May 1 and could impact about 30,000 people who have slightly higher incomes than traditional Medicaid beneficiaries.

“We’re not here to take everybody to the curb,” he said. Instead, he said, the aim is “making sure we get every able-bodied Nebraskan to be part of our community.”

The sweeping tax and policy law Trump signed in July requires states to make sure many recipients are working by 2027 but gave them the option to do it sooner.

Beneficiaries will have more reporting duties

The law mandates that people ages 19 to 64 who have Medicaid coverage work or perform community service at least 80 hours a month or be enrolled in school at least half-time to receive and keep coverage.

It applies only to people who receive Medicaid coverage through an expansion that covers a population with a slightly higher income limit. Forty states and the District of Columbia have opted to expand the coverage income guidelines under former President Barrack Obama’s 2010 health insurance overhaul.

Of 346,000 Nebraska residents enrolled in Medicaid as of May, about 72,000 were in the higher income expansion group.

Some people will be exempted, including disabled veterans, pregnant women, parents and guardians of dependent children under 14 or disabled individuals, people who were recently released from incarceration, those who are homeless and people getting addiction treatment. States can also offer short-term hardships for others if they choose.

All Medicaid beneficiaries who are eligible because of the expansion will be required to submit paperwork at least every six months showing they meet the mandate.

Those who don’t would lose their coverage.

The reporting requirement is twice as frequent as it is for most people covered by Medicaid now. That change means more work for the state agencies — and for some of them, extensive and likely expensive computer program updates.

Pillen said he does not expect the state government to increase staffing to make the changes.

When and how to implement the change is likely to be on the agenda for governors and state lawmakers across the country as legislative sessions start — most of them in January.

The policy is expected to lead to lost coverage

The nonpartisan Congressional Budget Office estimates that the requirement will reduce Medicaid costs by $326 billion over a decade — and that it will result in 4.5 million people becoming uninsured each year starting in 2027. Currently, about 77 million Americans are covered by Medicaid.

Because most people covered by Medicaid who are able to work already do, it’s not expected to increase employment rates.

Mehmet Oz, the administrator of the Centers of Medicare and Medicaid Services, joined Pillen’s announcement via a video feed and said the administration believes there are jobs available across the country, and the challenge is connecting people with them.

“Most people who are able-bodied on Medicaid actually want to get a job,” Oz said.

Georgia implemented similar requirements in 2023. Far fewer people are covered than projected, in part because of the work and reporting requirements.

Arkansas tried another variation of Medicaid work requirements — later blocked by a judge — that saw 18,000 people kicked off coverage in the first seven months after it took effect in 2018.

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