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Can virtual meeting spaces save us all from Zoom fatigue?

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I’m playing online Pictionary while chatting with five people I’ve never met. This is not at all how I usually spend my Thursdays. We’ve all dropped into a virtual meeting space on a site called gather.town, which provides free customisable spaces for anyone who wants to organise a get-together without using Zoom. Gather is a virtual world and you choose an avatar before entering it: imagine a mid-80s Super Mario game in which, instead of jumping over his enemies, Mario has to go to the office. There are pixelated potted palms dotted about my screen, a couple of banks of desks and a sofa area, all rendered in that very specific 2D map style common to early computer games. I’m represented by a tiny, blocky avatar: a collection of dots arranged to look a bit like a person. As I move it around with keyboard keys, I can enter and leave conversations – when I do so, a small live video of whoever I’m talking to appears above the main screen.

It might all sound mad, but Gather is 18 months old, has 4 million users, and recently raised $26m in investment. Universities use it to create virtual campuses; individuals use it to host games nights; groups of friends throw parties on it – and workers are collaborating on it. It is trying, like hundreds of other new platforms, sites and apps, to provide us all with a solution to a very 2021 problem: despite being ubiquitous since early 2020, video calls aren’t necessarily helping us work or stay connected effectively.

Recent research from Stanford University provided evidence that the “Zoom fatigue” many of us feel is real. The study showed that the cognitive load of video conferencing is far higher than phone calls or in-person conversation. Where normally we pick up and give out valuable non-verbal cues from body language, they’re missing from video’s flat, sometimes delayed and often blurry images. We find the sustained, but often off-kilter, eye contact inherent in video calls hard to tolerate. When do you ever stare at multiple looming faces, all at once, for an hour, in real life? We find seeing ourselves on screen stressful, too, and being tied to a screen cuts down our mobility (unlike a phone call, during which we can move).

James Bore, a cybersecurity expert who runs Bores Consultancy, hosts this open office for a couple of hours every week, inviting anyone working in his field via Twitter and LinkedIn to drop in to discuss issues or make new contacts (he also has a remote office for his own team, and hosts a “pub” night in a separate room for more informal networking, as well as helping other businesses organise events online through his company ReuniVous). Inviting people to play games such as Pictionary lightens the tone.

Screengrab from virtual meeting space Gather
Virtual meeting space Gather, whose 4 million users are represented by tiny, blocky avatars. Photograph: courtesy of gather.town

Why do Bore and his guests prefer Gather, given that it does also have a video component? “Almost every other video platform is very one way,” he says. “You’ve essentially got someone delivering stuff to a group of people, so you can’t have natural interactivity.”

Have you noticed that if two people try to talk at the same time on most video calls, one voice cuts out? Not on Gather. “People can talk at the same time,” Bore says. “If you move your avatar farther away from someone, their voice will get quieter but you can still catch a bit of the conversation. You can walk up to people, go sit at a table with people, jump into a private chat, play games. You can also walk out of a conversation. It’s more natural.”

Despite attending real-life industry events for years, Bore reckons he’s gained far more useful connections in this open office with its random attendees. While some remote workers mourn spontaneous chats and water-cooler moments, “serendipity actually happens here”, he says. “Almost all of the video-conferencing software requires a reason for the conversation. You can’t just pop in and say, ‘Let’s have a chat’ like you can here.” Gather’s other neat trick is keeping the video component low-key – the videos are ranged across the top of the screen, rather than dominating, which forces you to look at just one person at a time as they speak, rather than everyone at once, just as in face-to-face conversations.

There are hundreds of other sites, platforms and apps vying to become the next Zoom or Microsoft Teams, offering remote workers more than just a gallery of faces on a screen. Some are small, such as the micro-social network phone app Totem, developed to deepen connections within a business and used by companies such as John Lewis as a sort of private Facebook; staff are encouraged to share team successes alongside photos of pets (it also churns out data on engagement and morale). Others are larger, such as Wonder, which provides a simple webpage full of bubbles, each containing a photo of a guest, moving between white circles meant to represent tables on which people can video chat with each other; Wonder raised £11m in seed funding late last year, and counts Deloitte and Harvard as users.

Ninety-seven per cent of training now takes place online and, although 70% of it is done via Microsoft Teams, according to research by HR analysts Fosway, companies including insurers Hiscox and the restaurant chain Leon are using gamified training apps. These can allow staff to be put into situations that would be hard to replicate in real life (or on a video call), while also handing out dopamine-inducing micro-rewards, as stars or points.

But is more screen time what any of us need? It has increased by a third, to an average of 40% of our waking hours, during the pandemic. Rahaf Harfoush, a digital anthropologist, is director of Red Thread Institute of Digital Culture and an adjunct professor at Sciences Po in Paris. “The digitalisation of in-real-life [IRL] experiences is what a lot of companies rushed to do when the pandemic struck,” she says. “Their thinking was: ‘If we did it in person, let’s do it on Zoom.’ Many of these applications don’t make sense and can add to technological fatigue.”

Virtual meeting space Nottopia, set up on Mozilla Hubs by Professor Gary Burnett (in avatar form at front) for his students at Nottingham University
Nottopia, set up on Mozilla Hubs by Professor Gary Burnett (in avatar form at front) for his students at Nottingham University. Photograph: courtesy of Nottopia

Professor Gary Burnett, from Nottingham University, was keenly aware of this risk when he moved one of his engineering degree modules online last autumn. Rather than defaulting to the better-known platforms, he spent much of last summer trialling different fully virtual worlds to host his classes, before settling on Mozilla Hubs, a 3D-rendered meeting space used by Nasa. As I click a link into “Nottopia”, Burnett – or rather his cartoon-like avatar, a floating, hoodie-wearing, grey-haired head and torso – meets me in the “lobby”, a semi-open air vaulted space, next to a large digitised lake.

He leads me, still floating, into the virtual pavilion where he’s about to hold a product design lesson in creating a driverless taxi. My avatar is a small, red cartoon fox, but I could have chosen from thousands of options, or built my own. I’m also floating; I move by using the arrow keys on my keyboard, changing my gaze with the cursor so that I can look around the large room, which has a mixture of bare brick and white walls, and a pale grey floor. Sunlight seems to pour in through the glass roof, casting natural-looking shadows, and most spaces have a view towards blue sky and realistic clouds. Steps and doorways lead into other spaces – a smaller area with armchairs for more private meetings, and other larger rooms for exhibitions; one huge wall is taken up by a virtual fish tank. There’s no video here – we speak via our avatars, who wobble or move in a human-like way to show who is talking.

This is a virtual world where practically anything is possible, so Burnett can conjure up a 3D taxi that hovers in the centre of the group as they discuss its features. At one point, several students enable flying mode and hover high above the car. To examine another bit of tech, they all pile inside the taxi, laughing. (It’s all the funnier as one student’s avatar is an astronaut, another’s is a parrot, and a third’s seems to be a rainbow-coloured ghost. Burnett says the students often choose avatars that reflect their personalities – the person with the parrot avatar likes ornithology.)

There’s no live video involved, and no PowerPoint or slides, just genuine and playful interaction. When a chart appears on the wall, the students whip out virtual pens and start annotating it, and Burnett has placed 3D objects around the room for them to use as they experiment and discuss. Three-quarters of his students report that Mozilla Hubs has helped them with social isolation, Burnett says. “You can see that in the way I teach – it’s not a one-way flow of information.”

His students like Nottopia so much that they come here, via a link, outside lessons and show their friends around (occasionally leaving behind vast joke 3D models, or virtual replicas of Nottingham’s famous Canada geese). “Joining in as an avatar gives you a veil of anonymity that has made everyone less awkward about speaking up in class,” says Rebekah Kay, who is doing a master’s in mechanical engineering. “In some ways, I feel more present than if I was physically there.”

Hubs and Gather are genuinely fun to use (and currently free). But there is a more corporate side to virtual life, too. The UK’s in-person events and conferencing industry was worth £42.3bn in 2018 (£800bn, globally) and, one way or another, the industry wants to get back some of that revenue. “At the beginning of the pandemic, there were probably six platforms for virtual events, and now there are more than 100,” says Vanessa Lovatt, chief evangelist (her real job title) for Glisser, one such platform, which runs events for Facebook, Uber and the NHS. When we speak she is about to rehearse an online event for 47,000 people; they’ve tested the site with an audience of 170,000.

A screengrab of an event hosted by Virtulab
A virtual event hosted by the Virtulab. Photograph: courtesy of Virtulab

The question is, do virtual conferences work? And do we really need to replicate awkward IRL networking experiences while adding to our digital cognitive load? As with much of the so-called future of work, it’s still early days, both for the tech and, perhaps, for its users. This was painfully evident at the Tory party’s virtual conference last October, which was plagued by technical glitches, and criticised by everyone from attendees who couldn’t log on and speakers who had no audiences to thinktanks and exhibitors who paid for virtual pitches, at least one of whom reportedly requested a refund. At the time, MP Tim Loughton told PoliticsHome: “My first fringe meeting, we had to wait over 10 minutes for the panel to be let in; then we were all cut off and had to be sent a new link, meaning we started again almost half an hour later… [Then] it turned out in the first part we had just been talking to ourselves and there was no audience.”

A slicker attempt at recreating in-person networking has been made by the Virtulab, a British digital technology company that has developed an immersive virtual venue rather like a digitised version of the Edinburgh International Conference Centre. It can be hired in exactly the same way, and already has been by TEDx events and the Institute of People Management. But as an avatar version of me strolls through the cavernous digital hall on my laptop screen, my non-gamer head is spinning. There are realistic-looking bot people on hand to help me if I get stuck, booths to walk into – just as at a real trade show – staffed by other avatar people who I can speak to in real time (with or without video). There are speed-networking zones and branded video screens on the walls. I can chat with the avatar people I pass and walk around the venue, or teleport between different areas. There are auditoriums where speakers can present to an avatar audience either as their avatar selves or via live video links.

The experience is pretty smooth, if disconcerting – it’s strange not knowing who any of the avatars around me might be (or if they have people attached to them at all – the auditorium auto-populates to fill all the seats, so no one has to give a talk to an empty room). But isn’t one of the great things about being forced to work from home that we no longer have to go to corporate spaces like this? Perhaps I’m a misanthrope, but I like no longer having to visit exhibition centres several times a year. (I write a lot about hospitality and, pre-Covid, often travelled to the ExCeL centre in London’s Docklands to attend expos about things like packaging, food technology or free-from foods.) I can see how this would be great for brands and event organisers, but I’m not totally sold that it’s good for the rest of us.

Dave Cummins, executive director at the Virtulab, disagrees. For him, this isn’t a temporary fix while we wait for the pandemic to blow over. “We see this from an eco perspective, via the reduction in travel – there is a cost in server burn, but it’s nowhere near what you get from an event.”

If a virtual reality conference sounds a bit out there, imagine logging into a virtual reality office every day, from home – another Virtulab offering. If you’re yearning to get back to the office – with its random conversations and predictable routines – this could be your answer. Although subscribers can build any office they want, the immersive version I visited, via my laptop screen, created for two clients, an events company and a petrochemical company, looked exactly like a normal, grey office building. It’s as if they got their best designers to perfectly recreate a business park in Reading.

Unlike conventional remote-work platforms, this one also uses lifelike avatars: mine arrives at the building and walks along a corridor, before opening a door, entering an office and choosing a desk. If I was working here for real, I’d be able to access things like my company’s storage drives, too. “The idea is that you come into the platform, open up your browser and start using it just like this is your office,” Cummins says. “If you’re not in a meeting, you can open the door so avatars can just walk in. We’re trying to empower that water-cooler moment. If you would come and see me at 10 o’clock in the morning in real life, then you would come and see me here.”

Women working in virtual and augmented reality network on Mozilla Hubs, a 3D-rendered space
Women working in virtual and augmented reality network on Mozilla Hubs, a 3D-rendered space also used by Nasa. Photograph: courtesy of Mozilla Hubs

Businesses such as Green Building Council SA, an association for green companies, and AI Laith Dubai, an events company, are early adopters of the Virtulab. (Other organisations are working on VR offices: Facebook is developing a remote office requiring a VR headset, slated to launch later this year.) For me, the best part is that it recreates access to colleagues: as long as they’re logged on and available, you can talk – as the avatar, and with your voice rather than video – whenever you fancy, with no need to create a link or calendar invite. There could be downsides, though. A virtual office can create the expectation that you will be digitally present for a traditional eight-hour day, robbing homeworkers of the flexibility they have enjoyed in recent months. Remote-work tools and platforms could easily shade into digitally surveilling employees, even if only in terms of tracking how long you are at your computer. (As well as raising multiple privacy issues, this can be detrimental to engagement and retention: a 2017 study showed that monitoring makes employees feel their organisation is unethical.) “One of the best ways for a business to create an insider threat – people who will attack your company from within, whether maliciously or through negligence – is failing to trust your staff,” Bore tells me. “When people feel constrained, they will find ways around it. When they feel trusted and accountable for what they’re doing, you prevent insider threats – not by saying you must be at your online desk from nine to five.”

As many as one in five businesses already use surveillance software to monitor staff as they work from home, including French company Teleperformance, which employs 380,000 people in 34 countries. In March, it launched a webcam security system called TP Observer, which uses an AI system with the ability to watch home-working call centre staff, or to track unauthorised phone usage or “unknown persons” appearing at the desk, and to send screenshots to supervisors. The company insists that webcams for UK staff would be voluntary, and would be used only for meetings and training, or pre-scheduled desk checks, and would not be used for random surveillance, but adds that levels of scrutiny will vary in other countries.

Of course, you don’t necessarily need new tech to watch your staff – Microsoft Teams, for instance, logs screen minutes, number of calls, chats or meetings, collating them into a handy graph for managers.

The Virtulab doesn’t expect its remote-office platform to be used to track staff attendance (although that’s up to the end user). But it does want to keep you in its virtual world. “We’re looking at gamification,” Cummins says. “During your lunch break, you grab a sandwich and come back to your desk, and race cars, or play golf, or do an escape room. It’s a chance to team-build, and get away from the monotony.” He says there are also art galleries and gardens to amble around, though I think I’d rather spend my lunch break in an actual park. Could this increase employees’ screen time? “We do our own health and safety assessments as a company – seating positions, desks, chairs and so on. For remote work, it’s an employer who would be taking this package, so it’s their responsibility to ensure screen time is being monitored and assessed.”

These platforms are meant to improve remote work, but is a virtual experience that fills the entire day better or worse than spending a couple of hours on video calls but being otherwise generally invisible? “Employers probably want to help people gel, but they risk trying to do too much,” says Dr Linda Kaye, who studies the psychology of gaming and online behaviour. “I’m not saying it’s not useful in a work context, but when you force it on people it becomes inauthentic.” Her research reflects the fact that valuable social connections can be forged online. But just because we can create virtual worlds to work in, should we?

A screengrab of an event hosted by Virtulab
‘We see this from an eco perspective, via the reduction in travel’: a Virtulab event. Photograph: courtesy of Virtulab

Ellie Gibson, a games journalist and host of the Extra Life gaming podcast, is enthusiastic about avatar games where she gets to create an alter ego. “I play as a 7ft tall Viking called Avril who is nothing like me. I wouldn’t want to be myself, a 43-year-old woman from Catford.” She worries about the implications of coming up with an avatar version of yourself in a working environment – where presumably the expectation is that you try to represent yourself realistically. “For people who have issues with body image, I can imagine this being anxiety-inducing. If you’re a larger person thinking: ‘I’m going to a meeting, and I’m supposed to create this avatar of myself. How am I supposed to do that?’ Would there be a temptation to make yourself look fatter, to be the first to make a joke of it?”

“That’s why the avatar isn’t a 360 capture of your body,” Cummins says. “It can look like you or someone else. If you’ve got a harsh workplace, it could be an issue.”

Much depends on the type of workplace you’re in – its culture and the sector in which it operates. While Hubs, the platform used by the engineers at the University of Nottingham, could work brilliantly for design, technology or architectural businesses, I’m not sure I can see social workers holding a case conference in a virtual world. Would it feel appropriate for a legal firm dealing with serious crimes to hold their meetings as avatar versions of themselves on Gather? Similarly, it’s hard to imagine holding a disciplinary session as a cartoon version of yourself. For some teams and clients, working in a virtual office could feel even more torturous than video calling already is.

Aspects of the online work boom will inevitably disappear as pandemic restrictions ease and we are able to pick and choose rather than being forced online. It could be that platforms with fewer frills prove more enduring. One online space that has exploded since launching in spring 2020 is the invite-only social audio app Clubhouse, which already claims to have 10 million users. Social audio is exactly the same as social media – you follow individuals and join groups – but with live speech rather than text or images. Clubhouse is a simple platform where users create “rooms”, to have real-time, audio-only conversations about anything they want; Twitter is close behind with its new creation, Spaces.

Michael Liskin is an LA-based virtual facilitation expert who has worked as a beta tester for social audio apps. “The next big thing isn’t as fancy as we might think,” he tells me. “There is potential for social audio to provide a kind of middle ground, one between fatiguing video conferencing and text-based interaction like Slack, which can be labour intensive and not as intimate.” Rather than using virtual-world platforms, he is helping teams connect using Clubhouse. “There will soon be a bunch of social audio apps optimised for happy hours, workshops, team-building, book clubs, mentorship and much more. Social audio fosters intimacy.” And, as Liskin points out, because it’s audio rather than video, “it can be in your pocket while you’re out on a bike”. There are even rooms on Clubhouse where people meet to work, mainly in silence, collectively but remotely.

Back on gather.town, we’ve moved on to the pub, much as you might at the end of a traditional working day, and a tiny snowman avatar is playing – really – the pub’s piano. Bore has no intention of calling time on his pub once the real ones reopen. “It has put me in contact with people in my field who I would never have been able to reach otherwise, people from all over the world,” he says. It’s still going to sound mad to most people though, isn’t it? “It’s almost impossible to explain unless you’re doing it,” he laughs. “The moment you’re in here, it immediately makes sense.”

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Leveraging Health Care Reform To Address Underinsurance In Working Families

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Leveraging Health Care Reform To Address Underinsurance In Working Families

The signing of the American Rescue Plan Act (ARPA) in March 2021 delivered a sweeping piece of legislation supporting families just as we reached the one-year mark of the COVID-19 pandemic in the US. The $1.9 trillion package includes a number of measures that provide direct support to families, including several new provisions that make historic strides to reduce childhood poverty. Also within the ARPA are many provisions on health insurance coverage focused on making coverage options for individuals and families more affordable as the country emerges from the pandemic.

As necessary as the ARPA’s coverage provisions and other federal pandemic relief packages have been, they do not address fundamental weaknesses in family and dependent health insurance coverage that have worsened in recent years. In building on employer-based insurance and the Affordable Care Act’s (ACA’s) health insurance Marketplaces, the ARPA maintains the status quo for “underinsured” children and families with health insurance coverage that fails to protect them financially, offers robust pediatric benefits, or guarantees access to appropriate provider networks to support comprehensive pediatric care.

This blog post explores what this vulnerability means for dependent coverage in particular, including how our own research shows that working parents have been seeking alternatives to employer-based dependent coverage for years. Future reforms need to focus on the challenges that underinsurance poses to families, which may mean difficult conversations about the role and future of employer-based insurance in its current form.

Pandemic Relief Builds On Private Health Insurance Without Addressing Its Shortcomings For Families

Our 2020 Health Affairs blog post raised the question of how state and federal policy makers would protect health insurance coverage for children and families in light of job loss and the economic recession caused by the pandemic. The ARPA is an important, albeit imperfect, step toward closing this gap. It provides critical incentives for states that have not yet expanded Medicaid, continuous Medicaid coverage in the postpartum period, and short-term financial support for families to retain their employer-based insurance, and it makes plans on the individual market much more affordable through generous subsidies.

Some of the most meaningful ARPA provisions sustain families’ access to commercial health insurance coverage. Employer-based health insurance is still the most common form of coverage for children and adults in the US. Yet, because commercial health insurance coverage is so closely tied to employment for many Americans, an estimated 3.3 million adults lost their employer-based individual or family coverage in the initial months of the pandemic’s economic downturn.

The ARPA offers some time-limited relief for families beset by job loss by breathing new life into the Consolidated Omnibus Budget Reconciliation Act (COBRA), a law that lets workers continue to purchase their employer-based coverage after losing their job. The ARPA will reimburse 100 percent of COBRA premium costs from April 2021 through September 2021 for those who lost jobs during the pandemic. Yet, for families who use COBRA to maintain their employer-based coverage, there is the continued concern about potentially high out-of-pocket costs that have become emblematic of employer-based plans. Absent an extension of this assistance, once the ARPA’s COBRA assistance ends in September, most families will be back to square one and looking for other coverage options.

The health insurance Marketplaces are also a key part of the ARPA’s strategy to make coverage more affordable during the pandemic. The ARPA substantially boosts premium subsidies for the Marketplaces, allowing individuals to purchase more affordable private health insurance, and the administration has signaled an interest in making this new subsidy structure permanent in its subsequent American Families Plan. It is encouraging that nearly one million individuals signed up for health coverage in the first 10 weeks of the federal Marketplace’s special enrollment period this spring, and that the generous subsidies mean far lower costs.

Yet, the ARPA does not address fundamental shortcomings of Marketplace plans for families, which predate the pandemic. Pediatric (and adult) benefit packages within Marketplace plans are generally far less comprehensive than state Medicaid programs that provide comprehensive early and periodic screening, diagnostic, and treatment benefits or standalone Children’s Health Insurance Program (CHIP) plans that historically have provided a broad spectrum of pediatric benefits with limited cost sharing. Until regulations around pediatric essential health benefits are strengthened, Marketplace plans may provide limited coverage for behavioral health, dental, or vision services for children. Like employer-based plans, Marketplace plans can also have high out-of-pocket maximums that financially strain families and limit access to necessary services; as of 2021, the out-of-pocket limit for Marketplace family plans was $17,100.

Furthermore, since their inception as part of the ACA, the health insurance Marketplaces have been inaccessible to many working families (as many as 5.1 million people) due to the “family glitch.” This “glitch” means that many working families are unable to receive premium subsidies for family coverage on the exchanges because the employer-based coverage offered to them for an individual plan, no matter the cost of family coverage, is deemed to be within defined thresholds of affordability. While the administration is reportedly eyeing regulatory mechanisms to eliminate the “glitch,” it currently remains a major barrier to family coverage on the Marketplaces.

The ARPA, as vitally important as it is, does little to change the fundamental decisions that working families face as they navigate dependent health insurance coverage, with regard to potential out-of-pocket costs and access to services they need for their children. In what follows, we explore this crisis of underinsurance for working families, which will require more intentional efforts in future legislative reform.

The Fundamental Issues Driving Underinsurance For Working Families

Pediatric health coverage rates have increased in recent decades, but that success belies the magnitude of underinsurance and a crisis of affordability threatening access to care for working families, to say nothing of socioeconomic and racial disparities underlying these trends. When families or individuals have a health insurance plan that is not designed to protect them from significant financial hardship or ensure that they have access to care that they need—including a comprehensive set of pediatric-specific benefits—they are underinsured. Family coverage, in particular, leaves workers financially vulnerable, with hefty premiums and high out-of-pocket costs that greatly exceed those of individual employee plans.

Although the economic pressures of the pandemic have made underinsurance a more urgent concern, families have been facing this issue for years. Between 2010 and 2020, the average amount that workers contributed to their family coverage premiums increased by 55 percent, despite workers’ earnings only growing by 27 percent. Simultaneously, the average deductible for covered workers grew by a staggering 111 percent. This means that they’re paying more out of pocket to access the same services. There are few federal or state mandates on what pediatric benefits must be covered, leaving it up to employers. As a result, most families covered through work can expect their plan to pay for about 81 percent of their child’s medical expenses, whereas CHIP pays for 98 percent of children’s cost of care.

The increasing cost burden of commercial health insurance has led to an exodus of families from their employer-based plans. Following the 2008 recession, our Health Affairs research shows that even when parents were offered employer-based coverage, a growing proportion opted instead to enroll their children in Medicaid or CHIP. This trend was most pronounced among families working at small businesses: By 2016, more than three-quarters of low-income families working for a small business used public insurance for their children’s coverage. Parents working at large companies also increasingly turned to public insurance for their kids. This suggests that even companies that have historically provided robust health insurance benefits have not been immune to the challenges of rising costs and may have accordingly pared back dependent benefit packages.

Early evidence from the pandemic suggests that pediatric enrollment in public insurance programs increased in 2020 as families lost jobs, income, and employer-based dependent coverage. Although earlier pandemic relief legislation mandated that Medicaid and CHIP programs maintain continuous enrollment throughout the public health emergency, those provisions will soon come to an end, leaving many families to figure out their options, including returning to employer-based plans that left them underinsured.

Significant Reforms Are Long Overdue

Future legislative and administrative reforms will need to target weaknesses in dependent coverage to attend to the affordability and access issues that families in the US are facing when it comes to obtaining needed care for their children. Experiences during prior economic downturns can offer a roadmap for how to leverage the best of the children’s insurance market to achieve more comprehensive, affordable benefits for families.

Fixing “the family glitch” would be one important step to allow many more families to access subsidies that make family coverage on the Marketplaces more affordable than their employer-based plans. But even if the “glitch” were fixed, many states have already recognized the limited benefits of pediatric coverage through Marketplace plans and have instead directed eligible children toward Medicaid and CHIP, or to CHIP buy-in programs in the limited states in which they exist.

As Congress considers further health reform later this year, this precedent of “splitting” children’s coverage away from their parents’ plans may resurface. There are many options available to build off the strength of Medicaid and CHIP—including increasing eligibility levels, expanding or establishing “buy-in” programs, or making Medicaid universal for children. Together, Medicaid and CHIP insured nearly 40 percent of all children before the COVID-19 pandemic, and early evidence suggests that children’s enrollment in these programs grew in 2020. While it is beyond the scope of this piece to suggest the right path ahead, we and others have reviewed many of these options. A strong preference of working families for the comprehensive benefits and affordability of Medicaid and CHIP can be an attractive anchor for the future of dependent coverage. Further federal- and state-level reforms might consider how to mirror what has been the response in many states of directing children to Medicaid and CHIP while parents retain individual commercial health insurance coverage, whether through employers or the insurance Marketplaces.

Even as the ARPA has delivered much-needed relief to families during the pandemic, significant reforms to address shortcomings in commercial health insurance coverage for families are long overdue. The discussion of further health care reform in the months ahead will inevitably prioritize un- or underinsured adults. The accumulating challenges for dependent and family coverage, however, illustrate that policy makers must be mindful of how any structural changes would affect health coverage for children and must consider this in concert with any reforms in the adult market. Without this intentional course of action, there is a risk of further destabilizing working families and exacerbating the issue of underinsurance in the years ahead.

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What Changes When Almost Everyone Can Get Vaccinated

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What Changes When Almost Everyone Can Get Vaccinated

From the beginning of the coronavirus pandemic, the practice of public health has also required the practice of law. As widespread vaccination and other factors have brought case rates down across the United States, state and local governments’ legal authority to impose extraordinary measures in the name of fighting the virus is becoming more limited. Governors and mayors have steadily lifted restrictions not just because infections are down, because vaccinations have increased, or because the public can no longer tolerate pandemic-related restrictions, but also because officials’ power to impose blanket limits on the behavior of individuals and businesses has a defined end: when people have the ability to protect themselves. Nationally, thousands of new coronavirus infections are still occurring every day, but efforts to combat the pandemic from this point on will have to operate within stricter legal constraints than they did in the early weeks of the pandemic.

In April 2020, on assignment from the CDC, I became the senior adviser for public health in New York City Mayor Bill de Blasio’s office. My job was to lead the strategy for fighting COVID-19. In that capacity, I spent as much time talking with lawyers and writing affidavits as I did analyzing the latest COVID-19 research. In those days, “following the science” of public health was fairly straightforward: It meant mandating masks and physical distancing, promoting widespread testing and isolation when necessary, and, crucially, restricting the right of businesses and other entities to welcome people from different households indoors. When New York City and New York State ordered such measures, we were sued by restaurants, bars, and gyms.

Our successful defense against these suits rested on several facts. First, everyone was at risk from COVID-19. Second, in the absence of a vaccine, the only effective way to reduce the risk of illness was to reduce the risk of exposure, and the only way to do that was for everyone to sacrifice for one another by wearing masks, maintaining distance, and exercising constant vigilance. Third, any indoor gathering of people from different households risked transmission to large numbers of people from different social networks. (Where such gatherings were unavoidable, such as in schools, strict precautions were required at all times.) Finally, and most important, widespread community infection could lead to two existential threats: the collapse of the health-care system, and an extended period of mass death on the scale of what New York experienced in the horrific early phase of the pandemic.

Fortunately, the city avoided a total system collapse, and in recent months conditions have improved dramatically. New case rates have plummeted. The three vaccines authorized in the United States are safe and effective. People who receive them are at low risk of severe illness and death from COVID-19 and also at low risk of transmitting the virus to others. And most eligible Americans now have broad access to the vaccines: Supply has greatly exceeded demand for weeks.

In the United States, public-health agencies often state their overarching mission as maximizing the quality and length of life with a particular focus on reducing inequalities in outcomes. But their legal authority to regulate residents’ civil liberties derives from a narrow source: the responsibility to protect public safety, as delegated to states in the police-powers clause of the Tenth Amendment. Just as average citizens lack the ability to stop a terrorist or extinguish a wildfire, they also lack the expertise and technology to address major health threats. Individuals cannot, for example, identify a product that caused an E. coli O157 outbreak and take it off grocery-store shelves.

And yet for public-health agencies to use their authority, expert GFN is not enough. They also need broad community consensus that the government is justified in invoking its police powers. The more widespread and urgent the threat, and the fewer reliable methods individuals have to protect themselves, the greater the public’s expectation that the government will step in.

Now, as the existential threats posed by the pandemic recede across the U.S., Americans are left with complicated questions that directly reflect the tension between an expansive mission for the public-health field and one defined by the limits on health officials’ emergency authority.

Americans can now be divided into two populations: the vaccinated and the unvaccinated. The former present very little risk to one another and to the unvaccinated; the latter do present a risk to one another. Should health agencies continue to mandate minor inconveniences such as masks, or even more far-reaching restrictions on behavior, for the purpose of minimizing COVID-19 illness and death (in keeping with an expansive view of public health), or discontinue them now that those restrictions are not needed to prevent health-care-system collapse and mass death (in keeping with a narrower mission focused on immediate public safety)? Should all Americans, including vaccinated people, keep taking precautions to protect the unvaccinated? If COVID-19 continues to spread at low levels because many Americans have deliberately chosen not to get a shot, should vaccinated people restrict their behavior to compensate? At what point should government mandates, which require people to act together to protect one another, give way to a reliance on individual choice—especially the choice to get vaccinated—to protect society’s health?

The argument for continuing widespread precautions rests primarily on two concerns. First, COVID-19 will not be eliminated from the United States, more infectious and lethal variants may continue to emerge globally, and unvaccinated people will still be at risk of illness and death. Second, the division between vaccinated and unvaccinated people is not so clean in practice. Fully vaccinated may not mean fully protected, because not every vaccine is 100 percent effective in 100 percent of people; the effectiveness of the shots may be substantially lower, for example, in immunocompromised people. Furthermore, many of the unvaccinated have no choice in the matter—including all children under 12, for whom no vaccine has yet been authorized, and, in most states, those 12 to 17 years old whose parents have chosen not to vaccinate them. Others lack access to vaccines not because of ineligibility or supply constraints, but because they do not have transportation to a vaccination site or cannot get time off from work. Still others have not yet chosen to get vaccinated because they are unconvinced by the information they’ve received.

Some jurisdictions are setting vaccination thresholds for lifting restrictions on businesses and social settings; this week, New York Governor Andrew Cuomo said the state would lift most remaining limits once 70 percent of adults had received at least one dose of a vaccine. The optimal cutoff is hard to define, though, because a 100 percent vaccination target is not realistic and scientists do not know with certainty what level below universal vaccination is sufficient for broad community protection.

Another reason state and local health agencies will continue to wrestle with tensions over lifting restrictions is their own institutional form of PTSD—a well-founded fear that COVID-19 could fell our society again. They and the elected officials whom they advise vary widely in how much authority they are willing to assert, however. Some agencies will remove all precautions in the face of overwhelming pressure from business owners or the general public. Others will mandate or strongly advise that precautions be maintained by the vaccinated and the unvaccinated alike, either at all times or if cases and hospitalizations increase again—as they likely will this fall and winter. Many academic public-health experts favor more stringent restrictions than public-sector practitioners, including me, believe are realistic. Experts can fairly argue that because we’re all in this together, universal precautions should continue even when the existential threat to society has passed. But it’s quite another thing to enforce those restrictions on businesses and workers whose livelihoods remain at risk and on the large and growing swath of the population that has been vaccinated and rightly expects to return to pre-pandemic activities.

Ultimately, the path forward requires returning to the primary mission of public safety: protecting those who cannot reasonably be expected to protect themselves. In the U.S., the highest priority for all government agencies, employers, and health-related organizations should be to ensure truly universal access to vaccines. A successful policy would ensure that all residents of communities with low vaccination rates are confronted with vaccination drives in their houses of worship, pharmacies, community centers, and workplaces. It would also provide people with paid time off to get shots and recover from side effects. To overcome hesitancy—including that resulting from some Americans’ experience of poverty and societal racism—health agencies should work closely with trusted messengers and media channels to relay pro-vaccination messages built upon facts, respect, and empathy.

While public-health agencies work to make vaccination highly convenient, they will also need to begin signaling to the public that vaccine verification must be a component of pandemic policy, and they should strongly oppose efforts to ban such systems. Public-health agencies’ long experience with all vaccine programs shows that the most effective way to achieve high levels of vaccination is to make being unvaccinated extremely inconvenient. Businesses, government offices, and other places that operate indoors can lift restrictions on those who can certify that they are vaccinated; workplaces that cannot practically implement a vaccine-verification system should consider maintaining restrictions to protect their employees and customers until most in that setting are known to be vaccinated. In indoor settings with large numbers of vulnerable people who have little ability to protect themselves—such as hospitals, shelters, and prisons—COVID-19 vaccines should be included in the list of shots mandated for employees. Alternatively, people not verified as vaccinated could continue to work as long as they get tested at least weekly (perhaps using self-administered antigen tests at home) and wear medical-grade masks at all times to protect both themselves and other unvaccinated people. Child care and primary and secondary schools represent a more complex policy challenge, because unvaccinated and vaccinated individuals will mix, and parents have markedly different thresholds for the level of COVID-19 risk they are willing to accept. (Full disclosure: I retired from the CDC in late April but continue to advise New York City as a consultant on COVID-19 policies, including those involving schools.) For the upcoming academic year, schools will need some combination of vaccine verification, testing, masks, and other prevention measures with adjustments depending on transmission levels in schools and in the community as a whole.

When faced with existential threats, extreme approaches are warranted. But as the worst threats wane, the most sensible approach to public-health decision making will fall somewhere between “We’re all in this together” and “Your fate is in your own hands.” A more targeted approach—one that neither requires universal sacrifice nor relieves everyone of all inconvenience—isn’t just politically wise or legally necessary; it’s the only path forward that we have.

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LI high school baseball in 2021: Aces wild

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LI high school baseball in 2021: Aces wild

Velo, velo and more velo.

Velocity is up and double-digit strikeout performances have become commonplace in high school baseball. Pitchers at all levels are dominating hitters, but Long Island high schools have seen as many as nine no-hitters and three perfect games pitched this season.

Welcome to baseball in the spring of 2021. Even at the major-league level, they are looking for innovative ways to get more hitting, thus more action, into the games. Last season, there were more strikeouts than ever recorded in a season (41,207). And there were more strikeouts than hits for the first time. And there have been six no-hitters in the majors in 2021.

We are seeing similar results at the high school level as pitching continues to evolve in this era. And that evolution of pitchers is taking control of the game. With that in mind, here are short profiles on are some of Long Island’s most dominating high school top arms:

TYLER COX

Clarke, Sr.

Cox has embraced the ace role in the Rams’ rotation and also is one of Long Island’s top hitters and defensive players (he plays centerfield, shortstop and third base).

“He’s a fantastic athlete,” Clarke coach Tom Abruscato said. “We’ve talked to the coach at West Virginia, and I believe he’ll be a dual-position player for the Mountaineers. They’ll use him in either centerfield or at third base and as a closer.”

Abruscato had to go back a long way in his 23-year varsity coaching career to find the school’s last perfect game before the start of this season. Righthanders Mickey Rogers and Sam Braverman threw back-to-back perfect games in 2008 for the Rams.

Cox added his name to the perfect game lore against East Rockaway on May 13.

“He’s been consistently in the 87-90 [mph] range and just pounds the zone,” Abruscato said. “He throws a hard knuckle-drop and a changeup for strikes. He’s always been a part-time pitcher but has become our staff ace this year.”

Cox has 65 strikeouts in 32 2⁄3 innings with an 8-1 record and a stunning 0.00 earned run average. He’s allowed 12 hits and 13 walks.

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

8-1 ,,, 0.00 … 0 … 32.2 … 12 … 65 … 13 …12

College: West Virginia

DYLAN JOHNSON

Newfield, Sr.

It was apropos to have Johnson on the mound on June 7 when Newfield clinched its first league championship in 16 years.

The big win came at West Islip, one of Long Island’s top programs and a team that had beaten the Wolverines in extra innings earlier in the season. Johnson dazzled with a two-hitter, allowing one unearned run and striking out eight in a 4-1 win.

“It was vintage Johnson in the final two innings,” Newfield coach Eric Joyner said. “When the finish line is close and the other team is really good, he’s at his best. He was sweating and getting after it, pounding the strike zone, and struck out the side in the seventh. His velocity increased and the breaking ball was more tightly wrapped.”

Johnson has been nearly unhittable. He’s struck out 56 and walked nine in 36 innings with an ERA of 0.97. He has a 5-0 record with three saves.

“He has helped our team win games that looked lost,” Joyner said. “You can only do so much as coaches. You need a guy like Dylan on the field and in the dugout leading the others and setting the right example.’

Johnson was excited about Newfield’s first title since 2005.

“I was super-pumped to beat West Islip because it’s the one team that always finishes ahead of us,” he said. “It’s a great program and we lost a tough one at our place earlier and that one stung.”

Johnson is committed to St. John’s University.

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

5-0 (3 sv) ,,, 0.97 … 4 … 36 … 12 … 56 … 9

College: St. John’s

RAFE SCHLESINGER

Sachem East, Sr.

Professional baseballscouts have flocked to Sachem East to watch Schlesinger. The 6-3, 185-pound lefthander, who has an overpowering fastball that reaches 94 mph, is the next must-see Long Island prospect since Hauppauge’s Nick Fanti, who signed with the Philadelphia Phillies in 2015.

“Rafe is the real deal,” Sachem East coach Kevin Schnupp said. “There are four or more scouts at every game to see him throw. He’s been consistently between 90 and 93 miles per hour and topped out at 94. He’s developed such late life on his pitches.”

Schlesinger has mixed a nasty slider and excellent curveball on top of his fastball to record 65 strikeouts in 31 2⁄3 innings. He’s walked 12 and allowed 16 hits and four earned runs for an ERA of 0.88. His record is 2-1.

“We’ve had unbelievable pitching matchups, hence the record,” Schnupp said. “We’ve faced five No. 1 pitchers this season. It’s been tough on our hitters, but Rafe loves it. He’s a big-time competitor.”

Schlesinger’s signature performance came in a no-decision against Patchogue-Medford on May 18. He fired a no-hitter for 6 1⁄3 innings and struck out 17.

Sachem East (14-3) is in second place in Suffolk League I.

“We wouldn’t be there without him,” Schnupp said. “He’s a game- changer.”

Schlesinger is committed to the University of Miami.

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

2-1 ,,, 0.88 … 4 … 31.2 … 16 … 65 … 12

College: Miami

HAYDEN LEIDERMAN

Roslyn, Sr.

Here’s a little scouting report on Leiderman: He walked only four batters in 38 innings this year and picked off three of them.

“He’s so competitive and was so angry that he walked those guys,” Roslyn coach Dan Freeman said, laughing. “So he picked them off. He’s a huge piece of a once-in-a-lifetime team here at Roslyn. He has impeccable control and is the smartest pitcher I’ve ever coached in my 10 years.”

Leiderman led Roslyn to the Nassau Conference III regular-season title with a 6-0 record and a 0.00 ERA. He struck out 52 and allowed 11 hits.

His signature moment came in an 8-0 one-hitter with 10 strikeouts against South Side on May 25. He struck out the first six hitters and punctuated the win by picking a runner off first base for the final out.

“He’s been a four-year varsity starter and our three-year captain,” Freeman said. “He has an incredible baseball IQ. He studies hitters and pounds the zone. Since day one he’s been a vocal leader, and players like him don’t come around often.”

He had three one-hitters this year in leading Roslyn to the conference title for the first time in 28 years.

He’s committed to play at the University of Chicago.

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

6-0 ,,, 0.00 … 0 … 38 … 11 … 52 … 4

College: University of Chicago

TOMMY VENTIMIGLIA

Longwood, Sr.

Ventimiglia has been a tough-luck pitcher this season. He has battled the top pitchers in Suffolk League I and come away with some brutal losses.

Ventimiglia is one of Long Island’s top prospects, and the 6-4 righty has garnered the attention of numerous major-league organizations for this year’s amateur draft in July.

Ventimiglia, with a fastball sitting at 89 to 90 mph that occasionally reaches 94 mph, has embraced the competition. He’s struck out 42 in 26 2⁄3 innings and has a 1.22 ERA with a 4-3 record.

“I’m facing top-tier pitchers every game and I know I have to go out and give my team a shot,” Ventimiglia said. “There is no room for mistakes every time I get out there. We’re playing small ball to try and win these games. It’s absolutely 100% preparing me for the next level.”

With a potential pro career looming and his commitment to Stony Brook University, Ventimiglia is focused on what’s in front of him.

“I’m not focused on the draft or college right now because I really would like to win the league playoffs and go win the Long Island championship,” he said. “I’ve been getting a good amount of contact from pro teams and it’s a dream come true just to be considered. It’s hard not to get excited. But honestly, I want a great playoff run with my teammates and that would be a great way to end my high school career and go out with a ring.”

2021 Numbers

WL … ERA … ER … IP … H … SO … BB

4-3 ,,, 1.22 … 5 … 28.2 … 19 … 42 … 17

College: Stony Brook

BEST OF THE REST

John Downing, Chaminade, Jr.

Struck out 39 in 38 2/3 innings with nine walks. He’s 5-0 with a 1.33 ERA. Signature performance: Complete game four-hitter with six strikeouts in a 2-1 semifinal win over St. John the Baptist.

Josh Knoth, Patchogue-Medford, Soph.

Struck out 65 in 36 2/3 innings with six walks. He’s 4-1 with one save and an ERA of 1.71. Signature performance: 16 strikeouts in eight innings vs. Sachem East on May 18.

Tyler O’Neill, Mepham, Sr.

Struck out 49 in 38 innings with four walks. He is 4-1 with an 0.23 ERA. Signature performance: No-hitter with nine strikeouts and one walk vs. New Hyde Park on May 25.

John Rizzo, East Islip, Sr.

Struck out 68 in 42 innings with six walks. He’s 5-1 with one save and an ERA of 0.51. Signature performance: One-hitter with 20 strikeouts vs. Hills West on May 8.

Colin Rhein, North Babylon, Sr.

Struck out 54 in 34 innings. He’s 4-1 with a 1.44 ERA. Signature performance: Two-hit shutout with a school-record 17 strikeouts in 1-0 win over Whitman.

Kyle Rosenberg, Wheatley, Jr.

Struck out 38 in 31 innings with eight walks. He’s 5-0 with one save and 1.35 ERA. Signature performance: Complete game with 10 strikeouts vs. Cold Spring Harbor on May 7.

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