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Doctor’s bills often come with sticker shock for patients − but health insurance could be reinvented to provide costs upfront

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theconversation.com – Michal Horný, Assistant Professor of Health Policy and Management, UMass Amherst – 2024-11-21 07:21:00

The price of the doctor’s visit you calculated online might not reflect what you’ll actually be billed.
CSA Images/Getty Images

Michal Horný, UMass Amherst

You have scheduled an appointment with a health care provider, but no matter how hard you try, no one seems to be able to reliably tell you how much that visit will cost you. Will you have to pay US$20, $1,000 – or even more?

Patients are increasingly on the hook for health care costs through deductibles, co-pays and other fees. As a result, patients are demanding credible cost information before appointments to choose where they seek care and control their budget.

Yet, in spite of recent legislation and regulations, upfront information on patient out-of-pocket costs is still difficult to obtain from both health care providers and insurers.

Predicting out-of-pocket costs

Why is it so difficult to tell patients in advance how much their care is going to cost?

This is a question health economists like me try to answer. Although the fundamental reason is simply the unpredictable nature of health care, the fact that it translates to unpredictable out-of-pocket costs for patients is a policy choice.

Health insurance plans in the U.S. such as Medicare and Medicare Advantage, as well as most individual and group plans, leave a percentage of the cost of care for patients to settle out of pocket. These include deductibles – the amount patients have to pay for a service before their insurance kicks in – or coinsurance, a percentage of the cost of care that patients must pay after they have met their deductible.

Understandably, most patients want to know their out-of-pocket costs before a doctor’s office visit or a trip to the hospital. However, the cost of care – and thus the percentage of the cost patients will pay – often isn’t available until after care has been delivered. This is because of the way health care providers are paid for their work.

Stethoscope lying on top of health insurance bill
How many health care services you’ll need for a given illness or procedure can be unpredictable.
DNY59/E+ via Getty Images

Health care providers typically seek payments for each patient retrospectively, based on the volume and intensity of services they have delivered. But both are hard to predict. A physician usually needs to see a patient before deciding how to address their health care needs. Sometimes, an extra test or imaging scan is needed to confirm a diagnosis or plan treatment.

Crucially, a variety of unexpected complications can occur even during routine procedures. Addressing these unforeseen complications often requires providing unanticipated services and involving other health care providers who might not have been part of the visit otherwise. And these extra services cost money.

As long as policymakers keep health care payments tied to the volume and intensity of performed medical services – which are uncertain – and patient cost-sharing tied to health care payments, patients will not be able to know what their out-of-pocket costs will be in advance. Simply making health care service prices publicly available will not change that.

What can be done to guarantee out-of-pocket costs before patients have their appointments?

Health care delivery as a supply chain

One idea researchers have proposed is to reorganize health care delivery into a supply chain. This would shift production risk to health care providers similarly to how other complex products are offered to consumers.

Consider air travel tickets. Consumers taking a flight from one city to another receive services from multiple entities, such as airlines, airports, aviation fuel suppliers and catering companies. Many of these entities face operational uncertainties such as departure delays or variable fuel consumption due to unpredictable weather. But airlines – as the final link in the supply chain – provide consumers with upfront prices for the entire trip.

The No Surprises Act reduces patient bills from out-of-network providers.

In health care, the principal provider from whom a patient seeks care could serve as the price-guaranteeing entity. They would collect a single, guaranteed price for the appointment and compensate other providers involved as needed. Some researchers have proposed aspects of this idea as a potential way to reduce surprise billing from out-of-network emergency physicians working at in-network hospitals.

However, such a major reorganization of health care delivery would be extremely challenging, as it would require all providers to enter into new contractual arrangements with each other. It would not only cause a legal undertaking of unprecedented scale, but it could also end up being financially devastating for small physician practices.

Co-payment-only health plans

There are other approaches to providing patients with reliable, upfront prices that would not require a complete overhaul of the health care system. The U.S. already has much of the needed infrastructure in place: health insurance.

A primary purpose of health insurance is to protect beneficiaries from financial shocks. Health insurers could modify the benefit design of policies to ensure patients obtain guaranteed out-of-pocket cost information before receiving care.

One way to achieve that would be saying goodbye to deductibles and coinsurance and having insured patients pay for their care only in the form of co-paymentsfixed dollar amounts per encounter, such as $20 per doctor’s visit, $35 per prescription drug fill or $500 per hospital stay. Some insurance plans already offer this.

However, this approach removes incentives for patients to seek care from providers that offer quality services at a low price. It also could potentially increase monthly health insurance costs, also called premiums.

Person with head in hand in front of laptop, holding medical bill as another person looks on with them
Improving how health care is delivered could make for more transparent out-of-pocket costs for patients.
skynesher/E+ via Getty Images

Innovative health insurance design

Based on my own research, I propose that an alternative solution to providing patients with reliable, upfront prices could be implementing episode-based cost-sharing into health insurance plans.

Under this model, health insurers would create bundles of services that patients may receive during a health care visit. This approach would provide patients with a single upfront price for the entire bundle based only on factors known in advance, such as their health insurance benefits and who their principal health care provider is. For example, you would have a guaranteed price tag for the cost of going to the hospital to give birth to a child or replace a joint.

Any deviation from the ultimate cost of care due to unforeseen situations patients have little control over would be borne by the insurer. That is what insurers do for a living – they know how to manage risk. Such a modification to health insurance benefit design would protect patients from unexpected health care costs, while preserving the incentive to seek care with high-value providers. It would also help keep health insurance premiums intact.

Seeking care for a health concern is already stressful. It does not have to be more stressful because of cost uncertainty. Several approaches to help patients know how much their care is going to cost in advance are available for policymakers to consider. In the meantime, patients may need to pick up the phone, call their hospital billing office and hope that the amount they obtain will be close to the amount they will eventually find on their medical bills.The Conversation

Michal Horný, Assistant Professor of Health Policy and Management, UMass Amherst

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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I’m an economist. Here’s why I’m worried the California insurance crisis could triggerbroader financial instability

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theconversation.com – Gary W. Yohe, Huffington Foundation Professor of Economics and Environmental Studies, Wesleyan University – 2025-01-21 07:42:00

Gary W. Yohe, Wesleyan University

The devastating wildfires in Los Angeles have made one threat very clear: Climate change is undermining the insurance systems American homeowners rely on to protect themselves from catastrophes. This breakdown is starting to become painfully clear as families and communities struggle to rebuild.

But another threat remains less recognized: This collapse could pose a threat to the stability of financial markets well beyond the scope of the fires.

It’s been widely accepted for more than a decade that humanity has three choices when it comes to responding to climate risks: adapt, abate or suffer. As an expert in economics and the environment, I know that some degree of suffering is inevitable — after all, humans have already raised the average global temperature by 1.6 degrees Celsius, or 2.9 degrees Fahrenheit. That’s why it’s so important to have functioning insurance markets.

While insurance companies are often cast as villains, when the system works well, insurers play an important role in improving social welfare. When an insurer sets premiums that accurately reflect and communicate risk — what economists call “actuarially fair insurance” — that helps people share risk efficiently, leaving every individual safer and society better off.

But the scale and intensity of the Southern California fires — linked in part to climate change, including record-high global temperatures in 2023 and again in 2024 — has brought a big problem into focus: In a world impacted by increasing climate risk, traditional insurance models no longer apply.

How climate change broke insurance

Historically, the insurance system has worked by relying on experts who study records of past events to estimate how likely it is that a covered event might happen. They then use this information to determine how much to charge a given policyholder. This is called “pricing the risk.”

Many California wildfire survivors face insurance struggles, as this ABC News report shows.

When Americans try to borrow money to buy a home, they expect that mortgage lenders will make them purchase and maintain a certain level of homeowners insurance coverage, even if they chose to self-insure against unlikely additional losses. But thanks to climate change, risks are increasingly difficult to measure, and costs are increasingly catastrophic. It seems clear to me that a new paradigm is needed.

California provided the beginnings of such a paradigm with its Fair Access to Insurance program, known as FAIR. When it was created in 1968, its authors expected that it would provide insurance coverage for the few owners who were unable to get normal policies because they faced special risks from exposure to unusual weather and local climates.

But the program’s coverage is capped at US$500,000 per property – well below the losses that thousands of Los Angeles residents are experiencing right now. Total losses from the wildfires’ first week alone are estimated to exceed $250 billion.

How insurance could break the economy

This state of affairs isn’t just dangerous for homeowners and communities — it could create widespread financial instability. And it’s not just me making this point. For the past several years, central bankers at home and abroad have raised similar concerns. So let’s talk about the risks of large-scale financial contagion.

Anyone who remembers the Great Recession of 2007-2009 knows that seemingly localized problems can snowball.

In that event, the value of opaque bundles of real estate derivatives collapsed from artificial and unsustainable highs, leaving millions of mortgages around the U.S. “underwater.” These properties were no longer valued above owners’ mortgage liabilities, so their best choice was simply to walk away from the obligation to make their monthly payments.

Lenders were forced to foreclose, often at an enormous loss, and the collapse of real estate markets across the U.S. created a global recession that affected financial stability around the world.

Forewarned by that experience, the U.S. Federal Reserve Board wrote in 2020 that “features of climate change can also increase financial system vulnerabilities.” The central bank noted that uncertainty and disagreement about climate risks can lead to sudden declines in asset values, leaving people and businesses vulnerable.

At that time, the Fed had a specific climate-based example of a not-implausible contagion in mind – global risks from sudden large increases in global sea level rise over something like 20 years. A collapse of the West Antarctic Ice Sheet could create such an event, and coastlines around the world would not have enough time to adapt.

In a 2020 press conference, Federal Reserve Chair Jerome Powell discusses climate change and financial stability.

The Fed now has another scenario to consider – one that’s not hypothetical.

It recently put U.S. banks through “stress tests” to gauge their vulnerability to climate risks. In these exercises, the Fed asked member banks to respond to hypothetical but not-implausible climate-based contagion scenarios that would threaten the stability of the entire system.

We will now see if the plans borne of those stress tests can work in the face of enormous wildfires burning throughout an urban area that’s also a financial, cultural and entertainment center of the world.The Conversation

Gary W. Yohe, Huffington Foundation Professor of Economics and Environmental Studies, Wesleyan University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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How nonprofits pitch in before, during and after disasters strike

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theconversation.com – Vanessa Crossgrove Fry, Associate Research Faculty/Interim Director, Boise State University – 2025-01-21 07:41:00

Social Border Grill delivers food as part of World Central Kitchen relief efforts at an Eaton Fire temporary shelter in Pasadena, Calif., on Jan. 9, 2025.
Kirby Lee/Getty Images

Vanessa Crossgrove Fry, Boise State University

Los Angeles is reeling after fires of historic proportions raced through many communities in January 2025, destroying thousands of homes. The Conversation U.S. asked Vanessa Crossgrove Fry, an associate research professor and director of the Idaho Policy Institute at Boise State University, and an expert on sustainable management and nonprofit administration, to explain what role nonprofits can play in staving off disasters and dealing with them when and after they occur.

What’s the role of nonprofits when disasters strike?

They play a critical role by complementing government efforts and filling gaps in immediate and long-term recovery needs.

Collaboration is a hallmark of how nonprofits respond to disasters. These organizations often work alongside government agencies and private sector partners in coordinated efforts. This approach ensures that aid is distributed efficiently, directing resources where they are needed most.

Often, national groups lead efforts to establish emergency shelters, distribute food and water, and offer mental health support. In a best-case scenario, these large organizations partner with local nonprofits that are uniquely positioned to mobilize quickly, leveraging their deep understanding of community needs and established trust with residents.

In some disasters, especially large ones like the Lahaina, Hawaii, fire in 2023, nonprofits also act as coordinators. They make sure that volunteers, donations and other resources flow to people who need help.

Nonprofits’ flexibility and community-based networks enable them to respond to local challenges, such as supporting displaced families or addressing unmet needs in underserved areas. Beyond immediate relief, many nonprofits remain involved in long-term recovery efforts, assisting with rebuilding homes, restoring livelihoods and fostering community resilience.

Two women sit at a table crowded with food, but look desolate.
While surrounded by food donations, Evangeline Balintona, left, and her sister Elsie Rosales, sit inside a hotel-condo after they both lost homes in Lahaina to the wildfire, Sept. 1, 2023, in Kahana, Hawaii.
AP Photo/Marco Garcia

What do nonprofits do before disasters occur?

Nonprofits play a crucial role in disaster preparedness by working to reduce risks and build resilience.

In fire-prone regions like the Los Angeles foothills, organizations often focus on educating the public, helping residents understand fire risks and creating evacuation plans. They also implement fire mitigation strategies, such as spreading awareness about the importance of clearing brush and replacing wooden roofs.

Nonprofits also run community training programs, such as CPR certification or Community Emergency Response Team – CERT – training, or Sound the Alarm events to empower residents to respond effectively during emergencies.

With CERT training, a local fire department might equip volunteers to prepare for the hazards they’re likely to face in their communities. That kind of exercise empowers them with essential disaster-response skills, including fire safety and light search and rescue know-how. During Sound the Alarm events, smoke detectors are installed in vulnerable communities and residents get help creating evacuation plans.

Partnerships with government agencies, private companies and other nonprofits should ideally be in place before a disaster occurs to ensure a coordinated response when the time comes.

For example, nonprofits may establish agreements about setting up emergency shelters or accessing and distributing food supplies. They also build networks to ensure vulnerable populations – such as low-income residents, people experiencing homelessness, and those with disabilities – are included in disaster planning and response efforts.

Other roles include advocating for more funding for disaster preparedness and infrastructure, like wildfire-resistant construction or community-wide firebreaks – areas of cleared vegetation.

In some cases, nonprofits may help coordinate the use of government resources. For instance, Idaho Department of Insurance Director Dean Cameron recently drafted a bill that’s pending in the Idaho Legislature that would provide funding for homeowners to make fire mitigation upgrades on their property.

Additionally, nonprofits often develop detailed contingency plans for their own operations so they can continue to deliver services during a crisis.

Through these proactive measures, nonprofits help communities prepare for the worst while fostering resilience that can temper the long-term impacts of disasters.

What does the situation in LA have in common with what happens in Idaho?

Los Angeles and Idaho might seem worlds apart, but when it comes to handling disasters like wildfires, they face surprisingly similar challenges.

Both places grapple with dry seasons, rising temperatures and increasing invasive vegetation that amplify wildfire risks. Climate change is exacerbating these conditions, making fires more frequent and intense.

In Los Angeles, urban sprawl has expanded development into fire-prone areas, known as the wildland-urban interface. Similarly, Idaho has seen increased development in the wildland-urban interface surrounding Boise – where the population is surging.

This type of growth poses significant risks to both homes and lives as seen in Idaho’s 2016 Table Rock Fire and the more recent 2024 Valley Fire.

In addition, wildfires in Idaho’s forested and rural areas put not only people and infrastructure at risk, but can impact valuable grazing land, as occurred in the 2024 Wapiti Fire.

In both regions, balancing the demand for housing with the need for fire-resilient planning and mitigation measures is a critical challenge.

Another shared concern for nonprofits in Idaho and California is ensuring that vulnerable populations receive enough support during and after disasters. In both urban and rural settings, people experiencing homelessness, low-income families, and those in remote areas may have a lot of trouble evacuating, accessing resources and rebuilding after disasters.

Firefighters spray down the rubble of burned homes.
A firefighter from Idaho sprays down the rubble of homes demolished by the Eaton Fire in Altadena, Calif., on Jan. 15, 2025.
Photo by Frederic J. Brown/AFP via Getty Images

What are some common misconceptions about nonprofits in disasters?

Many people tend to think that nonprofits only provide immediate relief, such as food, shelter or medical care. While these services are critical in the early stages of a disaster, many nonprofits also focus on long-term recovery and rebuilding efforts.

Nonprofits may help communities rebuild homes, restore livelihoods or address emotional trauma months – or even years – after a disaster occurs.

There is also a tendency to overlook the role of local nonprofits. High-profile national organizations often command the public’s attention, but local nonprofits are often better positioned to address community-specific needs and work directly with vulnerable populations.

These misunderstandings can lead to the underfunding – and underappreciation – of local nonprofits.

Should people still donate to established organizations?

There are more ways to give to people experiencing a crisis than there used to be.

You might hesitate to donate to large nonprofits after a big disaster like the Los Angeles fires, for several reasons. Maybe you’re concerned about transparency or the group’s effectiveness. It might feel less personal to you than giving money, say, to a GoFundMe campaign.

I think that people should still consider donating to large and established organizations, but I also believe that it’s important to do so thoughtfully. Large nonprofits, such as the American Red Cross or Salvation Army, often have the infrastructure, expertise and logistical capacity to mobilize quickly and scale their operations to address disasters effectively.

These organizations also maintain established relationships with government agencies, local nonprofits and international partners. Those networks facilitate coordinated responses that smaller or newer groups might struggle to achieve.

However, the emergence of giving options, such as crowdfunding platforms, grassroots campaigns and community-based nonprofits, has expanded opportunities for individuals to direct their support to specific causes or populations. These avenues can make a big difference, particularly when donors want to address local or niche needs. Still, newer or less established groups may lack transparency or accountability.

Established organizations tend to have robust financial oversight and accountability systems in place. They are often better equipped to address not only immediate relief needs but also long-term recovery efforts, which smaller or informal groups may not have the capacity to support.

To be sure, it’s always wise to do some research before giving money to a cause of any kind.

Ultimately, the choice depends on your own priorities. Do you want to support immediate relief, contribute to systemic solutions or help a specific community?

By donating to both large organizations and local efforts alike, you can maximize your impact and help ensure everyone in a community gets support. And that’s important, especially after a disaster as big as the Los Angeles wildfires.The Conversation

Vanessa Crossgrove Fry, Associate Research Faculty/Interim Director, Boise State University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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Luce, a cartoon mascot for Catholic Church’s 2025 Jubilee, appeals to a younger generation while embracing time-honored traditions

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theconversation.com – Virginia Raguin, Distinguished Professor of Humanities Emerita, College of the Holy Cross – 2025-01-21 07:38:00

The Vatican introduces Luce at the Lucca Comics and Game convention in 2024.
https://www.youtube.com/watch?v=uKiGMGkc0xk screenshot via Wikimedia.com, CC BY

Virginia Raguin, College of the Holy Cross

Luce, the anime-inspired official mascot for the Catholic Church’s 2025 Jubilee, whose name means “light” in Italian, has been getting a lot of attention on social media. Some people love the cartoon and find her “cute,” but a few others consider her “unsuitable” and even “repugnant.”

The Vatican introduced Luce at a comics convention in Italy, with the goal of engaging young people and speaking about the theme of hope.

Designed by Simone Legno, the mascot with big blue eyes and blue hair, and rosary beads around her neck, represents a Catholic pilgrim. She is dressed in pilgrimage garments that were standard attire throughout the centuries. Her badge, the Pilgrimage of Hope, identifies the 2025 Jubilee. It shows blue, green, yellow and red figures embracing a cross that ends in an anchor at the base, a symbol of hope. The figures form an outline of a ship sailing over the waves, evoking images of travel.

I have long been interested in the central role played by pilgrimage in many faith traditions, culminating in an exhibition and book, “Pilgrimage and Faith: Buddhism, Christianity, and Islam” in 2010. Luce brings a contemporary perspective to the time-honored Christian pilgrimage tradition.

Pilgrimage symbols

The symbols that Luce carries serve as a reminder of the origins of Christian pilgrimage, which began with visits to the Holy Land, the place where Christ lived his life.

This pilgrimage was documented by a person who came to be known as the Anonymous Pilgrim of Bordeaux. He wrote in his diary “The Bordeaux Pilgrim” in 333 about his trip to the Holy Land when the basilica of the Holy Sepulcher, the site where Jesus was buried and is believed to have resurrected, was still under construction.

Luce carries symbols that have been associated with pilgrimage in Europe since the 12th century, particularly those connected to the shrine of St. James in northwestern Spain.

This Holy Land pilgrimage built a tradition of Christians not just visiting the holy sites but also returning with tangible souvenirs, such as a stone from the Holy Land, water from a well, or even a piece of cloth or a statue that touched Christ’s tomb. A sixth-century painted box now in the Vatican contains bits of soil and stones as souvenirs of places in the Holy Land.

A painting of a saint with a halo around his head and a staff in his hand.
St. James, depicted as a pilgrim on a stained-glass window at the monastery of Wettingen, Switzerland.
Virginia Raguin, CC BY

The pilgrimage to honor St. James, one of Christ’s apostles, whose tomb was believed to have been found in northwestern Spain, became popular in the early 12th century. The pilgrimage route was called the Way of St. James, Camino de Santiago de Compostela. The pilgrimage guided the faithful through several routes across Spain, France and Portugal, culminating in Santiago de Compostela in Galicia, in the north of Spain.

The itinerary of the journey, written in 1137 by an anonymous Frenchman, names natural landmarks, local customs and specific churches built to honor different saints. Along this route flowed artistic, economic and cultural exchanges. As was customary, pilgrims who returned after visiting St. James’ tomb adopted an emblem. Since the shrine was close to the sea, James’ symbol became a scallop shell that pilgrims wore to demonstrate their achievement.

Pilgrims were proud of these voyages that entailed much physical hardship as well as devotion. In the church of Santa Prassede, Rome, Giovanni de Montpoli, who describes his trade as preparing medicines, commissioned a 13th-century tomb slab showing himself as a pilgrim. He is dressed in a pilgrim’s fur overcoat to repel rain and retain warmth. He carries a staff and wears a wallet slung over his shoulder. A scallop shell adorning his broad-brimmed hat indicates that he had traveled to Compostela.

The popularity of the pilgrimage to St. James persisted through the Renaissance, supported by pilgrimage fraternities that helped people find companions for the journey and stay connected with each other after they returned. Sometimes subgroups of the fraternity even sponsored pilgrimage-related art such as a stained-glass window.

Evidence of such activities is seen in the monastery of Wettingen, near Zurich in Switzerland. St. James is depicted as a pilgrim in a stained-glass window dated 1522, donated by a Hans Hünegger and Regina von Sur. He wears a cloak and a hat decorated with pilgrim badges.

Pilgrim badges

A stained glass window depicts two men, each holding a staff, with one gazing up at the sky.
St. Louis of France wears scallop shell pilgrim emblems, Sainte-Clotilde, Paris, 1855.
Virginia Raguin, CC BY

By the middle decades of the 12th century, metal pilgrim badges were produced at low costs. They were soon available at shrines throughout Europe. Each pilgrimage location had its own distinctive badge.

Santiago’s scallop shell remained a universal pilgrim emblem over the centuries. A 19th-century stained-glass window in the church of Sainte-Clotilde in Paris shows 13th-century French King Louis IX – the only French monarch to be named a saint – with scallop shells on his cloak, even though his pilgrimage was to Jerusalem, not the shrine of Santiago.

A sketch of a man on a white marble slab.
Tomb slab of Giovanni de Montpoli, late 13th century, church of Santa Prassede, Rome.
Virginia Raguin, CC BY

Sometimes the Supper at Emmaus, when Christ met two disciples after his resurrection, was depicted showing the disciples as contemporary pilgrims.

One of the most memorable examples is Caravaggio’s painting from 1601, in the National Gallery in London, showing an astonished apostle wearing a scallop shell on his vest.

Luce, the pilgrim

Luce continues, as well as transforms, these traditions. In her large eyes gleam two scallop shells that reflect this thousand-year-old symbol. Like Giovanni de Montpoli in Rome, she wears a coat that shields her from the elements and she carries a staff. The yellow of the cloak references the color of the flag of Vatican City.

Like the 16th-century Swiss image of St. James, she wears a pilgrimage badge, this one proclaiming the Pilgrimage of Hope of the 2025 Jubilee. Her muddy boots indicate outdoor hiking, with which any young person can identify. She is depicted as female, representing all people, not just women.

Drawn in a contemporary and globally popular style, she suggests an openness to new encounters across the world.The Conversation

Virginia Raguin, Distinguished Professor of Humanities Emerita, College of the Holy Cross

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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