Tracy Gleason, Wellesley College and Stephanie Madsen, McDaniel College

The coach, the specialized equipment, the carefully tailored exercise regimen – they’re all key to athletic performance. But imagination might be an unexpected asset when it comes to playing sports.

The idea that athletic achievement depends on the mind isn’t new. Sport psychologists have known for years that working with an athlete on their mental game – visualizing the skill, kinesthetically feeling the swing – has a positive impact on actual performance. But these mental simulations draw only upon mental imagery – seeing and feeling the physical goals in the mind’s eye. Imagination offers a much wider range of possibilities.

What if your game could be helped by an imaginary friend?

In a recent retrospective study of college students, we discovered that imagination comes in handy in athletics in ways that are surprisingly social. The creation of what we termed imaginary athletes – a person or being that a child imagined in the context of athletics – enabled and motivated athletic play, especially for children between the ages of about 6 and 12. Imaginary athletes also provided companionship during athletic play.

Remembering childhood imaginary athletes

The most basic form of an imaginary athlete might be a wall, fence or even tree that makes a good opponent in a pinch. For a child or adolescent practicing a sport alone, a surface that provides a ball return or a steady target for a throw gives opportunities for practice usually requiring other players.

Is it any wonder, then, if the branches of the tree start to resemble a wide receiver’s arms, or an invisible goalie emerges in front of the fence? Solitary play might be a lot more fun if a make-believe teammate could provide an assist, or an invisible coach could appear and shout instructions during practice.

The college students in our study reported that such support, even if imaginary, made them play a little longer or try a little harder as kids.

About 41% of our sample of 225 college students reported creating at least one imaginary athlete at some point in middle childhood or early adolescence. Most, but not all, of these beings fell into three categories based on their characteristics.

The first we called placeholders, such as ghost runners. They are typically generic, amorphous, imaginary teammates created by groups of children when not enough real players are available.

The second type functioned as what we named athletic tools. They helped kids focus on their performance and improve their skills, usually by providing a worthy competitor, sometimes based on an admired professional athlete. The skills of athletic tools were often just above those of the child, drawing out the desire to be better, stronger, faster.

Social relationships, our name for the third kind of imaginary athlete, primarily served emotional functions, relieving loneliness and providing the child or adolescent with a sense of belonging, safety or companionship as they engaged in their sport.

Students who remembered imaginary athletes differed from their peers in two ways. First, more men than women reported creating these imaginary beings, possibly owing to the greater investment in and importance of athletics among boys versus girls. Second, people with imaginary athletes scored higher than those without on a current-day measure of predilection for imagination, but they were not more likely to report having created a make-believe friend or animal as a child.

Imagination is a valuable power

Creating an imaginary other might seem like a quirky, perhaps even childish, addition to sports practice. But actually, this behavior is entirely logical. After all, imagination is the core of human thought. Without it, we couldn’t conceptualize anything outside of the present moment that wasn’t already stored in memory. No thinking about the future, no consideration of multiple outcomes to a decision, no counterfactuals, daydreams, fantasies or plans.

Why wouldn’t people apply such a fundamental tool of day-to-day thought in athletic contexts? Participation in sports is common, especially among school-age kids, and many college students in our study described drawing upon their imaginations frequently when playing sports, especially when doing so in their free time.

The creation of imaginary athletes is also unsurprising because it’s one of myriad ways that imagination enhances people’s social worlds throughout their lives. Above all else, social relationships are what matter most to people, and using imagination in thinking about them is common. For instance, people imagine conversations with others, particularly those close to them, sometimes practicing the delivery of bad news or envisioning the response to a proposal of marriage.

In early childhood, kids create imaginary companions who help them learn about friendship and other’s perspectives. And in adolescence, when people focus on developing their autonomy and their own identities, they create parasocial relationships that let them identify with favorite celebrities, characters and media figures. Even in older age, some widows and widowers imagine continued relationships with their deceased spouses. These “continuing bonds” are efforts to cope with loss through imaginary narratives that are fed by and extrapolate upon years of interactions.

At each point in their developmental trajectory, people might recruit imagination to help them understand, manage, regulate and enjoy the social aspects of life. Imaginary athletes are merely one manifestation of this habit.

Because so many children and adolescents spend a lot of time engaged in sports, athletics can be a major environment for working on the developmental tasks of growing up. As children learn about functioning as part of a group, forming, maintaining and losing friendships, and mastering a range of skills and abilities, imaginary athletes provide teammates, coaches and competitors tailored to the needs of the moment.

Of course, an imaginary athlete is but one tool that children and adolescents might use to address developmental tasks such as mastering skills or negotiating peer relationships. Children who aren’t fantasy-prone might create complex training regimens to practice their skills, and they might manage their friendships by talking through problems with others.

But some report that turning inward generated real athletic and social benefits. “I got confidence out of my [imaginary athletes],” reported one participant. “If I could imagine beating someone, and [winning], then I felt like I could do anything.”

Tracy Gleason, Professor of Psychology, Wellesley College and Stephanie Madsen, Professor of Psychology, McDaniel College

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

Kevin Morris, University of Denver and Jaci Gandenberger, University of Denver

In a 2022 survey of 3,000 U.S. adults, more than one-third of respondents reported that on most days, they feel “completely overwhelmed” by stress. At the same time, a growing body of research is documenting the negative health consequences of higher stress levels, which include increased rates of cancer, heart disease, autoimmune conditions and even dementia.

Assuming people’s daily lives are unlikely to get less stressful anytime soon, simple and effective ways to mitigate these effects are needed.

This is where dogs can help.

As researchers at the University of Denver’s Institute for Human-Animal Connection, we study the effects animal companions have on their humans.

Dozens of studies over the last 40 years have confirmed that pet dogs help humans feel more relaxed. This would explain the growing phenomenon of people relying on emotional support dogs to assist them in navigating everyday life. Dog owners have also been shown to have a 24% lower risk of death and a four times greater chance of surviving for at least a year after a heart attack.

Now, a new study that we conducted with a team of colleagues suggests that dogs might have a deeper and more biologically complex effect on humans than scientists previously believed. And this complexity may have profound implications for human health.

How stress works

The human response to stress is a finely tuned and coordinated set of various physiological pathways. Previous studies of the effects of dogs on human stress focused on just one pathway at a time. For our study, we zoomed out a bit and measured multiple biological indicators of the body’s state, or biomarkers, from both of the body’s major stress pathways. This allowed us to get a more complete picture of how a dog’s presence affects stress in the human body.

The stress pathways we measured are the hypothalamic-pituitary-adrenal, or HPA, axis and the sympathoadrenal medullary, or SAM, axis.

When a person experiences a stressful event, the SAM axis acts quickly, triggering a “fight or flight” response that includes a surge of adrenaline, leading to a burst of energy that helps us meet threats. This response can be measured through an enzyme called alpha-amylase.

At the same time, but a little more slowly, the HPA axis activates the adrenal glands to produce the hormone cortisol. This can help a person meet threats that might last for hours or even days. If everything goes well, when the danger ends, both axes settle down, and the body goes back to its calm state.

While stress can be an uncomfortable feeling, it has been important to human survival. Our hunter-gatherer ancestors had to respond effectively to acute stress events like an animal attack. In such instances, over-responding could be as ineffective as under-responding. Staying in an optimal stress response zone maximized humans’ chances of survival.

More to the story

After cortisol is released by the adrenal glands, it eventually makes its way into your saliva, making it an easily accessible biomarker to track responses. Because of this, most research on dogs and stress has focused on salivary cortisol alone.

For example, several studies have found that people exposed to a stressful situation have a lower cortisol response if they’re with a dog than if they’re alone – even lower than if they’re with a friend.

While these studies have shown that having a dog nearby can lower cortisol levels during a stressful event, suggesting the person is calmer, we suspected that was just part of the story.

What our study measured

For our study, we recruited about 40 dog owners to participate in a 15-minute gold standard laboratory stress test. This involves public speaking and oral math in front of a panel of expressionless people posing as behavioral specialists.

The participants were randomly assigned to bring their dogs to the lab with them or to leave their dogs at home. We measured cortisol in blood samples taken before, immediately after and about 45 minutes following the test as a biomarker of HPA axis activity. And unlike previous studies, we also measured the enzyme alpha-amylase in the same blood samples as a biomarker of the SAM axis.

As expected based on previous studies, the people who had their dog with them showed lower cortisol spikes. But we also found that people with their dog experienced a clear spike of alpha-amylase, while those without their dog showed almost no response.

No response may sound like a good thing, but in fact, a flat alpha-amylase response can be a sign of a dysregulated response to stress, often seen in people experiencing high stress responses, chronic stress or even PTSD. This lack of response is caused by chronic or overwhelming stress that can change how our nervous system responds to stressors.

In contrast, the participants with their dogs had a more balanced response: Their cortisol didn’t spike too high, but their alpha-amylase still activated. This shows that they were alert and engaged throughout the test, then able to return to normal within 45 minutes. That’s the sweet spot for handling stress effectively. Our research suggests that our canine companions keep us in a healthy zone of stress response.

Dogs and human health

This more nuanced understanding of the biological effects of dogs on the human stress response opens up exciting possibilities. Based on the results of our study, our team has begun a new study using thousands of biomarkers to delve deeper into the biology of how psychiatric service dogs reduce PTSD in military veterans.

But one thing is already clear: Dogs aren’t just good company. They might just be one of the most accessible and effective tools for staying healthy in a stressful world.

Kevin Morris, Research Professor of Social Work, University of Denver and Jaci Gandenberger, Research Associate of Social Work, University of Denver

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

Lauren S. Hughes, University of Colorado Anschutz Medical Campus and Kevin J. Bennett, University of South Carolina

The public health provisions in the massive spending package that President Donald Trump signed into law on July 4, 2025, will reduce Medicaid spending by more than US$1 trillion over a decade and result in an estimated 11.8 million people losing health insurance coverage.

As researchers studying rural health and health policy, we anticipate that these reductions in Medicaid spending, along with changes to the Affordable Care Act, will disproportionately affect the 66 million people living in rural America – nearly 1 in 5 Americans.

People who live in rural areas are more likely to have health insurance through Medicaid and are at greater risk of losing that coverage. We expect that the changes brought about by this new law will lead to a rise in unpaid care that hospitals will have to provide. As a result, small, local hospitals will have to make tough decisions that include changing or eliminating services, laying off staff and delaying the purchase of new equipment. Many rural hospitals will have to reduce their services or possibly close their doors altogether.

Hits to rural health

The budget legislation’s biggest effect on rural America comes from changes to the Medicaid program, which represent the largest federal rollback of health insurance coverage in the U.S. to date.

First, the legislation changes how states can finance their share of the Medicaid program by restricting where funds states use to support their Medicaid programs can come from. This bill limits how states can tax and charge fees to hospitals, managed care organizations and other health care providers, and how they can use such taxes and fees in the future to pay higher rates to providers under Medicaid. These limitations will reduce payments to rural hospitals that depend upon Medicaid to keep their doors open.

Second, by 2027, states must institute work requirements that demand most Medicaid enrollees work 80 hours per month or be in school at least half time. Arkansas’ brief experiment with work requirements in 2018 demonstrates that rather than boost employment, the policy increases bureaucracy, hindering access to health care benefits for eligible people. States will also now be required to verify Medicaid eligibility every six months versus annually. That change also increases the risk people will lose coverage due to extra red tape.

The Congressional Budget Office estimates that work requirements instituted through this legislative package will result in nearly 5 million people losing Medicaid coverage. This will decrease the number of paying patients at rural hospitals and increase the unpaid care hospitals must provide, further damaging their ability to stay open.

Additionally, the bill changes how people qualify for the premium tax credits within the Affordable Care Act Marketplace. The Congressional Budget Office estimates that this change, along with other changes to the ACA such as fewer and shorter enrollment periods and additional requirements for documenting income, will reduce the number of people insured through the ACA Marketplace by about 3 million by 2034. Premium tax credits were expanded during the COVID-19 pandemic, helping millions of Americans obtain coverage who previously struggled to do so. This bill lets these expanded tax credits expire, which with may result in an additional 4.2 million people becoming uninsured.

An insufficient stop-gap

Senators from both sides of the aisle have voiced concerns about the legislative package’s potential effects on the financial stability of rural hospitals and frontier hospitals, which are facilities located in remote areas with fewer than six people per square mile. As a result, the Senate voted to set aside $50 billion over the next five years for a newly created Rural Health Transformation Program.

These funds are to be allocated in two ways. Half will be directly distributed equally to states that submit an application that includes a rural health transformation plan detailing how rural hospitals will improve the delivery and quality of health care. The remainder will be distributed to states in varying amounts through a process that is currently unknown.

While additional funding to support rural health facilities is welcome, how it is distributed and how much is available will be critical. Estimates suggest that rural areas will see a reduction of $155 billion in federal spending over 10 years, with much of that concentrated in 12 states that expanded Medicaid under the Affordable Care Act and have large proportions of rural residents.

That means $50 billion is not enough to offset cuts to Medicaid and other programs that will reduce funds flowing to rural health facilities.

Accelerating hospital closures

Rural and frontier hospitals have long faced hardship because of their aging infrastructure, older and sicker patient populations, geographic isolation and greater financial and regulatory burdens. Since 2010, 153 rural hospitals have closed their doors permanently or ceased providing inpatient services. This trend is particularly acute in states that have chosen not to expand Medicaid via the Affordable Care Act, many of which have larger percentages of their residents living in rural areas.

According to an analysis by University of North Carolina researchers, as of June 2025 338 hospitals are at risk of reducing vital services, such as skilled nursing facilities; converting to an alternative type of health care facility, such as a rural emergency hospital; or closing altogether.

Maternity care is especially at risk.

Currently more than half of rural hospitals no longer deliver babies. Rural facilities serve fewer patients than those in more densely populated areas. They also have high fixed costs, and because they serve a high percentage of Medicaid patients, they rely on payments from Medicaid, which tends to pay lower rates than commercial insurance. Because of these pressures, these units will continue to close, forcing women to travel farther to give birth, to deliver before going full term and to deliver outside of traditional hospital settings.

And because hospitals in rural areas serve relatively small populations, they lack negotiating power to obtain fair and adequate payment from private health insurers and affordable equipment and supplies from medical companies. Recruiting and retaining needed physicians and other health care workers is expensive, and acquiring capital to renovate, expand or build new facilities is increasingly out of reach.

Finally, given that rural residents are more likely to have Medicaid than their urban counterparts, the legislation’s cuts to Medicaid will disproportionately reduce the rate at which rural providers and health facilities are paid by Medicaid for services they offer. With many rural hospitals already teetering on closure, this will place already financially fragile hospitals on an accelerated path toward demise.

Far-reaching effects

Rural hospitals are not just sources of local health care. They are also vital economic engines.

Hospital closures result in the loss of local access to health care, causing residents to choose between traveling longer distances to see a doctor or forgoing the services they need.

But hospitals in these regions are also major employers that often pay some of the highest wages in their communities. Their closure can drive a decline in the local tax base, limiting funding available for services such as roads and public schools and making it more difficult to attract and retain businesses that small towns depend on. Declines in rural health care undermine local economies.

Furthermore, the country as a whole relies on rural America for the production of food, fuel and other natural resources. In our view, further weakening rural hospitals may affect not just local economies but the health of the whole U.S. economy.

Lauren S. Hughes, State Policy Director, Farley Health Policy Center; Associate Professor of Family Medicine, University of Colorado Anschutz Medical Campus and Kevin J. Bennett, Professor of Family and Preventive Medicine, University of South Carolina

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