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Siderea ([personal profile] siderea) wrote2025-12-14 08:45 am
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Understanding Health Insurance: The Three-Stage Model [healthcare, US, Patreon]

Canonical link: https://siderea.dreamwidth.org/1891517.html


This is part of Understanding Health Insurance





The Three-Stage Model



When you have health insurance, you have a contract (health plan) with the insurance company that says that for the duration (the plan year) of the contract, you will pay them the agreed upon monthly fee every month (the premium), in exchange for them paying for your health care... some.

How much is "some"? Well, that depends.

To understand what it depends on, you have to understand the three-stage model that health plans are organized around.

This three-stage model is never described as such. It is implicit in the standard terms (jargon) of the health insurance industry, and it is never made explicit. There is no industry term (jargon) for the model itself. There are no terms (jargon) for the three stages. But health insurance becomes vastly easier to understand if you think about it in terms of the three-stage model that is hiding in just about every health plan's terms (agreements).

Read more: 12,170 (sic!) riveting words about health insurance in the US] )

This post brought to you by the 221 readers who funded my writing it – thank you all so much! You can see who they are at my Patreon page. If you're not one of them, and would be willing to chip in so I can write more things like this, please do so there.

Please leave comments on the Comment Catcher comment, instead of the main body of the post – unless you are commenting to get a copy of the post sent to you in email through the notification system, then go ahead and comment on it directly. Thanks!
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oursin ([personal profile] oursin) wrote2025-12-14 12:42 pm

(no subject)

Happy birthday, [personal profile] amindamazed and [personal profile] hhw!
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brainwane ([personal profile] brainwane) wrote2025-12-14 05:59 am
Entry tags:

Bush vs. Gore vid

Happened across this Bluesky post embedding a TikTok of a vid about Al Gore "losing" the 2000 election to George W. Bush, set to a Sabrina Carpenter song. Enjoyed and wanted to share.
muccamukk: Steve standing with his arms folded, looking disapproving. (Avengers: Judgy Arms)
Muccamukk ([personal profile] muccamukk) wrote2025-12-14 12:11 am

Random perspectives in time

Eighty years before this year, WWII ended.

Eighty years before WWII ended, the American Civil War ended.

So we are as far away from (or as close to) WWII, as the people in WWII were from (or to) the Civil War.

IDK, it's interesting to think about. Something Elizabeth Samet has written about, a bit, too.

I only wrote a very short version of that fic where Steve Rogers was a civil war vet, who was frozen until Tony from Iron Man Noir found him, but I was always fond of that idea.
oursin: Books stacked on shelves, piled up on floor, rocking chair in foreground (books)
oursin ([personal profile] oursin) wrote2025-12-13 04:32 pm
Entry tags:

What, to absolutely EVERYONE???

I think this is an absolutely terrible idea, and that they should be giving book tokens, and, okay, maybe recommendations, but letting people choose their books:

30 authors on the books they give to everyone

I am in particular stunned by the choices of Some People, e.g. Colm Tóibín's Christmas Downer:

There is a book I buy as a present that never goes out of fashion. It is The Good Soldier by Ford Madox Ford.... the extraordinary plot creeps up and bites you before you know where you are. The narrative curls and twists; the narrator knows too much or too little. But at some point the appalling and ingenious nature of the treachery – what is called “cheating” nowadays – becomes apparent and you feel that you have been let in on some intriguing and explosive secret. It is perfect, thus, for Christmas.

I am also beswozzled by what Tessa Hadley considers comfort reading: Rumer Godden??? Okay, some of her works fall into that category, but on the whole I would not consider the ones she does name - The River in particular - exactly comforting.

Much as I love them, I would not press into anyone's hands Middlemarch, The Fountain Overflows, Cold Comfort Farm or The Pursuit of Love, urging that they they must read this.

I am reminded of GB Shaw's rewrite of the Golden Rule, about not doing to others as you would be done by, as tastes differ.

Take it away, Sly and the Family Stone!

oursin: Sleeping hedgehog (sleepy hedgehog)
oursin ([personal profile] oursin) wrote2025-12-12 08:52 pm

Thundering up over the horizon....

Suddenly it seems like Christmas is more imminent than I thought - I was going, oh, it is only the beginning of December, and now we are nearly 2 weeks in and aaaaargh.

Anyway, I have managed to get off the book tokens for the great-nieces and nephews - I was waiting on my sister coming back to let me know that, yes, they are all still readers, and then looked again at her email in which she said, would let me know if not....

So I got on to that and I had clearly erased from memory how immensely tiresome Waterstones site is should you want to purchase physical gift cards for several people, you have to make a separate purchase for each one, moan groan, and quite soon reached point where credit cards went 'we are sending you OTP' as you put in details yet another time.

Am feeling a bit generally fratchy today after a night troubled with resurgence of hip issue - probably due to a certain amount of standing about at Institution of Which I Am Honoured to Be A Fellow's Party yestere'en.

Had a moderately agreeable time and pleasant conversation but am still irked that the email issue remains unresolved.

Also, having determined to ring opticians to confirm appointment for dilation test - after a very satisfactory, insofar as holding one's head in awkward positions and having lights flashed in one's eyes can be thus designated, eye-test on Wednesday, at which it was determined I did not need new glasses, hooray, hooray, person I was dealing with right at the end looked at my notes and asked how long it was since they did a dilation test, which resulted in booking me in for a week's time. However, did not get any confirmation, odd I thought since they had been inundating me with texts and emails reminding me of the eye-test. So I was going to ring them but then they rang, going ooops, we are actually closed that day for training, can we reschedule. So rescheduled.

muccamukk: Text: Love > Anger, Hope > Fear, Optimism > Despair. (Misc: Canadian Politics)
Muccamukk ([personal profile] muccamukk) wrote2025-12-12 12:44 pm
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Siderea ([personal profile] siderea) wrote2025-12-12 06:49 am
Entry tags:

Update [me, health, Patreon]

So, I, uh, got my RSI/ergonomics debugged!* I then promptly lost two days to bad sleep due to another new mechanical failure of the balky meat mecha and also a medical appointment in re two previous malfunctions. But I seem back in business now. The new keyboard is great.

Patrons, I've got three Siderea Posts out so far this month and it's only the 12th. I have two more Posts I am hoping to get out in the next three days. Also about health insurance. We'll see if it actually happens, but it's not impossible. I have written a lot of words. (I really like my new keyboard.)

Anyways, if you weren't planning on sponsoring five posts (or – who knows? – even more) this month, adjust your pledge limits accordingly.

* It was my bra strap. It was doing something funky to how my shoulder blade moved or something. It is both surprising to me that so little pressure made so much ergonomic difference, and not surprising because previously an even lighter pressure on my kneecap from wearing long underwear made my knee malfunction spectacularly. Apparently this is how my body mechanics just are.
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Siderea ([personal profile] siderea) wrote2025-12-12 06:17 am
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Choosing Health Insurance: HSAs: FYI re bronze, catastrophic plans [healthcare, US, Patreon]

Canonical link: https://siderea.dreamwidth.org/1890494.html


0.

Hey Americans (and other people stuck in the American healthcare system)! Shopping for a health plan on your state marketplace? Boy, do I have some information for you that you should have and probably don't. There's been an important legal change affecting your choices that has gotten almost no press.

Effective with plan year 2026 all bronze level and catastrophic plans are statutorily now HDHPs and thus HSA compatible. You may get and self-fund an HSA if you have any bronze or catastrophic plan, as well as any plan of any level designated a HDHP.

2025 Dec 9: IRS.gov: "Treasury, IRS provide guidance on new tax benefits for health savings account participants under the One, Big, Beautiful Bill"
Bronze and Catastrophic Plans Treated as HDHPs: As of Jan. 1, 2026, bronze and catastrophic plans available through an Exchange are considered HSA-compatible, regardless of whether the plans satisfy the general definition of an HDHP. This expands the ability of people enrolled in these plans to contribute to HSAs, which they generally have not been able to do in the past. Notice 2026-05 clarifies that bronze and catastrophic plans do not have to be purchased through an Exchange to qualify for the new relief.

If you are shopping plans right now (or thought you were done), you should probably be aware of this. Especially if you are planning on getting a bronze plan, a catastrophic plan, or any plan with the acronym "HSA" in the name or otherwise designated "HSA compatible".

The Trump administration doing this is tacit admission that all bronze plans have become such bad deals that they're the economic equivalent of what used to be considered a HDHP back when that concept was invented, and so should come with legal permission to protect yourself from them with an HSA.

Effective immediately, you should consider a bronze plan half an insurance plan.

Read more [3,340 words] )

This post brought to you by the 221 readers who funded my writing it – thank you all so much! You can see who they are at my Patreon page. If you're not one of them, and would be willing to chip in so I can write more things like this, please do so there.

Please leave comments on the Comment Catcher comment, instead of the main body of the post – unless you are commenting to get a copy of the post sent to you in email through the notification system, then go ahead and comment on it directly. Thanks!
oursin: hedgehog in santa hat saying bah humbug (Default)
oursin ([personal profile] oursin) wrote2025-12-12 09:37 am

(no subject)

Happy birthday, [personal profile] avendya, [personal profile] cesy, [personal profile] tazlet and [personal profile] trude!
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oursin ([personal profile] oursin) wrote2025-12-11 03:05 pm

More London and heritage links

This is rather news to me - I think of people protesting the enclosure of commons as doing this a) a lot earlier and in more rural parts: Today in London’s parklife: 1000s destroy enclosure fences, Hackney Downs, 1875:

The 1870s were a high point of anti-enclosure struggles in the London area, following on from a decade of (mostly, though not exclusively) peaceful campaigns to prevent large open spaces being developed in the 1860s. Wanstead Flats in 1871, Chiselhurst Common in 1876, Eelbrook Common (Fulham) in 1878, all saw direct action against fences, as part of long-running resistance against the theft of common land.
....
Many of these struggles were characterised by the large-scale involvement of radical movements, as London radicals, secularists and elements who would later help to form socialist groups made open space and working class access to it a major part of their political focus. Radical land agitation, notably through the Land and Labour League, was beginning to revive the question of access to land as a social question, and within cities this manifested as both battles to defend green space, and propaganda around the theft of the land from the labouring classes.

The struggle is not over:
Centuries of hard fought battles saved many beloved places from disappearing, and laws currently protect parks, greens and commons. But times change… Pressures change. Space in London is profitable like never before. For housing mainly, but also there are sharks ever-present looking to exploit space for ‘leisure’. And with the current onslaught on public spending in the name of balancing the books (ie cutting as much as possible in the interests of the wealthy), public money spent on public space is severely threatened.
Many are the pressures on open green spaces – the costs of upkeep, cleaning, maintenance,
improvement, looking after facilities… Local councils, who mainly look after open space, are struggling. Some local authorities are proposing to make cuts of 50 or 60 % to budgets for parks. As a result, there are the beginnings of changes, developments that look few and far between now, but could be the thin end of the wedge.
So you have councils looking to renting green space to businesses, charities, selling off bits, shutting off parks or parts of them for festivals and corporate events six times a year… Large parts of Hyde Park and Finsbury Park are regularly fenced off for paying festivals already; this could increase. Small developments now, but maybe signs of things to come. Now is the time to be on guard, if we want to preserve our free access to the green places that matter to us.

***

HEIR, the Historic Environment Image Resource:

HEIR’s mission is to rescue neglected and endangered photographic archives, unlock their research potential, and make them available to the public.
HEIR contains digitised historic photographic images from all over the world dating from the late nineteenth century onwards. HEIR’s core images come from lantern slide and glass plate negatives held in college, library, museum and departmental collections within the University of Oxford. New resources are being added all the time, including collections from outside the University.

***

Dragon’s teeth and elf garden among 2025 additions to English heritage list:

The heritage body publishes a roundup of unusual listings to draw attention to the diversity of places that join the national heritage list for England each year.
As well as the anti-tank defences, this year’s list of 19 places includes a revolutionary 1960s concrete university block, a model boat club boathouse built in 1933 by men who were long-term unemployed, and a magical suburban “elf garden”.

***

Art history is too important to be the preserve of the privileged:

The act of looking has become commodified as technology companies ‘mine and sell our attention like coal’, as Kee writes. Letting art history become endangered and drift further into elite status is not only unfair, it’s also perilous. ‘Art history gives you tools to interpret the visual world and makes you more of a critical viewer of political messages, advertising and a barrage of social media images,’ says Perry. ‘It’s dangerous if you can’t examine these things critically.’

oursin: hedgehog in santa hat saying bah humbug (Default)
oursin ([personal profile] oursin) wrote2025-12-11 09:36 am

(no subject)

Happy birthday, [personal profile] crookedeye!
oursin: Photograph of small impressionistic metal figurine seated reading a book (Reader)
oursin ([personal profile] oursin) wrote2025-12-10 07:10 pm

Wednesday went for the annual eye-test

What I read

Finished Saving Suzy Sweetchild, which has our protag not only dealing with the usual movie hassle but being called in to deal with the papers of a suddenly deceased in possibly suspicious circumstances academic, as well as (with the usual cohorts) trying to work out what exactly the game is with the apparent kidnapping for ransom of child star, who is beginning to age out of cuteness. We observe that the classic sleuths may sometimes have had two mysteries on their hands but very seldom had to multitask like this.

Some while ago I read an essay by Ursula Le Guin on the novels of Kent Haruf: I fairly recently picked up Our Souls at Night (2015), which is more or less novella length, as a Kobo deal, and it was well-written, and unusual if very low-key, and I daresay I might venture on more Haruf but am in no great rush to do so.

Then on to Upton Sinclair, The Return of Lanny Budd (1953) - perhaps not quite as good as the earlier entries in the series - some of it felt a bit info-dumpy - Lanny and his friends who are promoting peace face the problem of Soviet Stalinist Communism in the Cold War era. I can't help contemplating them and thinking that they are probably going to be sitting targets for HUAC in a few years' time, because they are coming at the issue from a democratic socialist perspective and I suspect their Peace Program is going to be considered deeply sus by McCarthyism. Also, Lanny jnr is going to be of draft age come the 1960s....

On the go

To lighten the mood, Alexis Hall, Audrey Lane Stirs the Pot (Winner Bakes All #3) arrived yesterday.

Up next

The new (double-issue) Literary Review

Also (what was in the straying parcel last week) Dickon Edwards (whom some of you may remember from LJ days?) Diary at the Centre of the Earth: Vol. 1.

oursin: hedgehog in santa hat saying bah humbug (Default)
oursin ([personal profile] oursin) wrote2025-12-10 09:44 am

(no subject)

Happy birthday, [personal profile] cofax7!
oursin: hedgehog in santa hat saying bah humbug (Default)
oursin ([personal profile] oursin) wrote2025-12-09 04:00 pm

Tidying up some tabs

London Pride has been handed down to us:

Busiest Thoroughfare of the Metropolis of the World - review of book on the history of The Strand.

Over 250,000 images of London from the collections at The London Archives and Guildhall Art Gallery

***

Heritage endangered:

On an old cobbled street in a market town, residents say hundreds of years of history are disappearing before their eyes as thieves keep stealing large slabs of Yorkshire stone.

The Royal Society of Medicine is putting some of its rarest books and photographs up for sale at Christie’s this month. Is this a case of medical negligence? Screaming. The GMC should strike them off.

Rare piece of Australia's Indigenous history captured on camera in the desert

According to a local anthropologist in Broome, the photos were taken by a nurse who was volunteering at the La Grange mission.
In his opinion, the images are extraordinary — one of the rare moments of "first contact" on the Australian continent to be captured on camera.
The originals were donated to a Catholic Church archive, which is not accessible to the public.
But it turns out there are copies. On a dusty CD buried in the boxes of an elderly author.

I have a lot of questions here about disinterring the original - I have very cynical thoughts about the church 'archive', as probably a storeroom in a basement somewhere - and in general things which are literally hidden in the (unprocessed, uncared for) archives of some institution.

And at this I can only fall on the floor, weeping and going 'the horror, the horror': [S]ome AI chatbots (such as ChatGPT, Gemini, Copilot, Bard and others) may generate incorrect or fabricated archival references.

***

Gender and learning:

The Real Way Schools are Failing Boys - though possibly, just de-emphasise competition, for starters???

Estrogen levels predict enhanced learning (at least in rats....)

oursin: hedgehog in santa hat saying bah humbug (Default)
oursin ([personal profile] oursin) wrote2025-12-09 09:36 am

(no subject)

Happy birthday, [personal profile] bibliofilen and [personal profile] nineveh_uk!
oursin: Illustration from medieval manuscript of the female physician Trotula of Salerno holding up a urine flask (trotula)
oursin ([personal profile] oursin) wrote2025-12-08 03:34 pm

Not the only one having those visions, Margaret....

Margaret Atwood seems to be claiming some kind of unusual prescience for herself when writing The Handmaid's Tale:

Speaking on BBC Radio 4’s Desert Island Discs, Atwood said she believed the plot was “bonkers” when she first developed the concept for the novel because the US was the “democratic ideal” at the time.

Me personally, I can remember that the work reading group discussed it round about the time it first came out - and I remarked that it was getting a lot of credit for ideas which I had been coming across in feminist sff for several years....

I think the idea of a fundamentalist, patriarchal, misogynist backlash was pretty much in people's minds?

I've just checked a few dates.

At least one of the potential futures in Marge Piercy's Woman on the Edge of Time (1976).

Margaret O'Donnell's The Beehive (1980) .

Suzette Haden Elgin's Native Tongue (1984) and sequels.

Various short stories.

Various works by Sheri Tepper.

I'm probably missing a lot.

And assorted works in which there was an enclave or resistance cell of women embedded in a masculinist society.

I honestly don't think a nightmare which was swirling around at the time is something that can be claimed as woah, weird, how did I ever come up with that?

I'm a bit beswozzled by the idea that in the early-mid 80s the USA was a shining city on a hill, because I remember reviewing a couple of books on abortion in US post-Roe, and it was a grim story of the erosion of reproductive rights and defensive rearguard actions to protect a legal right which could mean very little in practice once the 1977 Hyde Amendment removed federal funding, and an increasingly aggressive anti-choice movement.

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Siderea ([personal profile] siderea) wrote2025-12-08 07:42 am
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Understanding Health Insurance: A Health Plan is a Contract [US, healthcare, Patreon]

Canonical link: https://siderea.dreamwidth.org/1890011.html

This is part of Understanding Health Insurance





Health Insurance is a Contract



What we call health insurance is a contract. When you get health insurance, you (or somebody on your behalf) are agreeing to a contract with a health insurance company – a contract where they agree to do certain things for you in exchange for money. So a health insurance plan is a contract between the insurance company and the customer (you).

For simplicity, I will use the term health plan to mean the actual contract – the specific health insurance product – you get from a health insurance company. (It sounds less weird than saying "an insurance" and is shorter to type than "a health insurance plan".)

One of the things this clarifies is that one health insurance company can have a bunch of different contracts (health plans) to sell. This is the same as how you may have more than one internet company that could sell you an internet connection to your home, and each of those internet companies might have several different package deals they offer with different prices and terms. In exactly that way, there are multiple different health insurance companies, and they each can sell multiple different health plans with different prices and terms.

Read more... [7,130 words] )

This post brought to you by the 220 readers who funded my writing it – thank you all so much! You can see who they are at my Patreon page. If you're not one of them, and would be willing to chip in so I can write more things like this, please do so there.

Please leave comments on the Comment Catcher comment, instead of the main body of the post – unless you are commenting to get a copy of the post sent to you in email through the notification system, then go ahead and comment on it directly. Thanks!
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Siderea ([personal profile] siderea) wrote2025-12-08 07:41 am
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Understanding Health Insurance: Introduction [healthcare, US, Patreon]

Canonical link: https://siderea.dreamwidth.org/1889543.html


Preface: I had hoped to get this out in a more timely manner, but was hindered by technical difficulties with my arms, which have now been resolved. This is a serial about health insurance in the US from the consumer's point of view, of potential use for people still dealing with open enrollment, which we are coming up on the end of imminently. For everyone else dealing with the US health insurance system, such as it is, perhaps it will be useful to you in the future.





Understanding Health Insurance:
Introduction



Health insurance in the US is hard to understand. It just is. If you find it confusing and bewildering, as well as infuriating, it's not just you.

I think that one of the reasons it's hard to understand has to do with how definitions work.

Part of the reason why health insurance is so confusing is all the insurance industry jargon that is used. Unfortunately, there's no way around that jargon. We all are stuck having to learn what all these strange terms mean. So helpful people try to explain that jargon. They try to help by giving definitions.

But definitions are like leaves: you need a trunk and some branches to hang them on, or they just swirl around in bewildering clouds and eventually settle in indecipherable piles.

There are several big ideas that provide the trunk and branches of understanding health insurance. If you have those ideas, the jargon becomes a lot easier to understand, and then insurance itself becomes a lot easier to understand.

So in this series, I am going to explain some of those big ideas, and then use them to explain how health insurance is organized.

This unorthodox introduction to health insurance is for beginners to health insurance in the US, and anyone who still feels like a beginner after bouncing off the bureaucratic nightmare that is our so-called health care system in the US. It's for anyone who is new to being an health insurance shopper in the US, or feels their understanding is uncertain. Maybe you just got your first job and are being asked to pick a health plan from several offered. Maybe you have always had insurance from an employer and are shopping on your state marketplace for the first time. Maybe you have always gotten insurance through your parents and spouse, and had no say in it, but do now. This introduction assumes you are coming in cold, a complete beginner knowing nothing about health insurance or what any of the health insurance industry jargon even is.

Please note! This series is mostly about commercial insurance products: the kinds that you buy with money. Included in that are the kind of health insurance people buy for themselves on the state ACA marketplaces and also the kind of health insurance people get from their employers as a "bene". It may (I am honestly not sure) also include Medicare Advantage plans.

The things this series explains do not necessarily also describe Medicaid or bare Medicare, or Tricare or any other government run insurance program, though if you are on such an insurance plan this may still be helpful to you. Typically government-run plans have fewer moving parts with fewer choices, so fewer jargon terms even matter to them. Similarly, this may be less useful for subsidized plans on the state ACA marketplaces. It depends on the state. Some states do things differently for differently subsidized plans.

But all these different kinds of government-provided health insurance still use some insurance industry jargon for commercial insurance, if only to tell you what they don't have or do. So this post may be useful to you because understanding how insurance typically works may still prove helpful in understanding what the government is up to. Understanding what the assumptions are of regular commercial insurance will hopefully clarify the terms even government plans use to describe themselves. Just realize that if you have a plan the government in some sense is running, things may be different – including maybe very different – for you.



On to the first important idea: Health Insurance is a Contract.



Understanding Health Insurance
oursin: Frontispiece from C17th household manual (Accomplisht Lady)
oursin ([personal profile] oursin) wrote2025-12-07 06:31 pm
Entry tags:

Culinary

This week's bread: Country Oatmeal aka Monastery Loaf from Eric Treuille and Ursula Ferrigno's Bread (2:1:1 wholemeal/strong white/pinhead oatmeal), a bit dense and rough-textured - the recipe says medium oatmeal, which has seemed hard to come by for months now (I actually physically popped into a Holland and Barrett when I was out and about the other day and boy, they are all about the Supplements these days and a lot less about the nice organic grains and pulses, sigh, no oatmeal, no cornmeal, etc etc wo wo deth of siv etc). Bread tasty though.

Friday night supper: groceries arrived sufficiently early in the pm for me to have time to make up the dough and put the filling to simmer for sardegnera with pepperoni.

Saturday breakfast rolls: adaptable soft rolls recipe, 4:1 strong white/buckwheat flour, dried blueberries, Rayner's Barley Malt Extracxt, turned out very nicely.

Today's lunch: savoury clafoutis with Exotic Mushroom Mix (shiitake + 3 sorts of oyster mushroom) and garlic, served with baby (adolescent) rainbow carrots roasted in sunflower and sesame oil, tossed with a little sugar and mirin at the end, and sweetstem cauliflower (some of which was PURPLE) roasted in pumpkin seed oil with cumin seeds.