Most Americans Face Lower Tax Burden Than in the 80s

What Is Fair?:
Taxes are still a hot topic after the presidential election. But as a country that spends more than it collects in taxes, are we asking the right taxpayers to pay the right amounts?

BELLEVILLE, Ill. — Alan Hicks divides long days between the insurance business he started in the late 1970s and the barbecue restaurant he opened with his sons three years ago. He earned more than $250,000 last year and said taxes took more than 40 percent. What’s worse, in his view, is that others — the wealthy, hiding in loopholes; the poor, living on government benefits — are not paying their fair share.

Kirsten Luce for The New York Times

"I don't have the answer of where to pull back. I want the state parks to stay open. I want, I want, I want. I want Big Bird, I think it's beautiful. What don't I want? I don't know," said Anita Thole, a safety supervisor for a utility contractor.

“It feels like the harder we work, the more they take from us,” said Mr. Hicks, 55, as he waited for a meat truck one recent afternoon. “And it seems like there’s an awful lot of people in the United States who don’t pay any taxes.”

These are common sentiments in the eastern suburbs of St. Louis, a region of fading factory towns fringed by new subdivisions. Here, as across the country, people like Mr. Hicks are pained by the conviction that they are paying ever more to finance the expansion of government.

But in fact, most Americans in 2010 paid far less in total taxes — federal, state and local — than they would have paid 30 years ago. According to an analysis by The New York Times, the combination of all income taxes, sales taxes and property taxes took a smaller share of their income than it took from households with the same inflation-adjusted income in 1980.

Households earning more than $200,000 benefited from the largest percentage declines in total taxation as a share of income. Middle-income households benefited, too. More than 85 percent of households with earnings above $25,000 paid less in total taxes than comparable households in 1980.

Lower-income households, however, saved little or nothing. Many pay no federal income taxes, but they do pay a range of other levies, like federal payroll taxes, state sales taxes and local property taxes. Only about half of taxpaying households with incomes below $25,000 paid less in 2010.

The uneven decline is a result of two trends. Congress cut federal taxation at every income level over the last 30 years. State and local taxes, meanwhile, increased for most Americans. Those taxes generally take a larger share of income from those who make less, so the increases offset more and more of the federal savings at lower levels of income.

In a half-dozen states, including Connecticut, Florida and New Jersey, the increases were large enough to offset the federal savings for most households, not just the poorer ones.

Now an era of tax cuts may be reaching its end. The federal government depends increasingly on borrowed money to pay its bills, and many state and local governments are similarly confronting the reality that they are spending more money than they collect. In Washington, debates about tax cuts have yielded to debates about who should pay more.

President Obama campaigned for re-election on a promise to take a larger share of taxable income above roughly $250,000 a year. The White House is now negotiating with Congressional Republicans, who instead want to raise some money by reducing tax deductions. Federal spending cuts also are at issue.

If a deal is not struck by year’s end, a wide range of federal tax cuts passed since 2000 will expire and taxes will rise for roughly 90 percent of Americans, according to the independent Tax Policy Center. For lower-income households, taxation would spike well above 1980 levels. Upper-income households would lose some but not all of the benefits of tax cuts over the last three decades.

Public debate over taxes has typically focused on the federal income tax, but that now accounts for less than a third of the total tax revenues collected by federal, state and local governments. To analyze the total burden, The Times created a model, in consultation with experts, which estimated total tax bills for each taxpayer in each year from 1980, when the election of President Ronald Reagan opened an era of tax cutting, up to 2010, the most recent year for which relevant data is available.

The analysis shows that the overall burden of taxation declined as a share of income in the 1980s, rose to a new peak in the 1990s and fell again in the 2000s. Tax rates at most income levels were lower in 2010 than at any point during the 1980s.

Governments still collected the same share of total income in 2010 as in 1980 — 31 cents from every dollar — because people with higher incomes pay taxes at higher rates, and household incomes rose over the last three decades, particularly at the top.

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The New Old Age Blog: Forced to Choose: Nursing Home vs. Hospice

An older person, someone who will die within six months, leaves a hospital. Where does she go?

Almost a third of the time, according to a recent study from the University of California, San Francisco, records show she takes advantage of Medicare’s skilled-nursing facility benefit and enters a nursing home. But is that the best place for end-of-life care?

In terms of monitoring her vital signs and handling IVs — the round-the-clock nursing care the skilled-nursing facility benefit is designed to provide — maybe so. But for treating end-of-life symptoms like pain and shortness of breath, for providing spiritual support for her and her family, for palliative care that helps her through the ultimate transition – hospice is the acknowledged expert.

She could receive hospice care, also covered by Medicare, while in the nursing home. But since Medicare only rarely reimburses for both hospice and the skilled-nursing facility benefit at the same time, this hypothetical patient and her family face a financial bind. If she opts for the hospice benefit, which does not include room and board at the nursing home, then she will be on the hook for hundreds of dollars a day to remain in the facility.

She could use the hospice benefit at home, of course. But, “we know these patients are medically complex,” said Katherine Aragon, lead author of the study in The Archives of Internal Medicine, and now a palliative care specialist at Lawrence General Hospital in Massachusetts. “And we know that taking care of someone near the end of life can be very demanding, hard for families to manage at home.” And that assumes the patient has a family or a home.

For some patients, a nursing home, though possibly dreaded, is the only place that can provide 24/7 care.

But if she uses the skilled-nursing facility benefit to pay for room and board in a facility, she probably has to forgo hospice. (The exception: if she was hospitalized for something unrelated to her hospice diagnosis. If she has cancer, then trips and breaks a hip, she can have both nursing home coverage and hospice. If cancer itself caused the bone to fracture, no dice.)

Let’s acknowledge that these are lousy choices.

The study, using data from the National Health and Retirement Study from 1994 through 2007, looked at more than 5,000 people who initially lived in the community – that is, not in a facility. About 30 percent used the skilled-nursing facility benefit during the final six months of life; those people were likely to be over 85 and family members said, after their deaths, that they had expected them to die soon. (The benefit is commonly referred to as S.N.F., which people in the field pronounce as “sniff”).

The choice to use S.N.F. had ongoing repercussions. Almost 43 percent of those who used it died in a nursing home and almost 40 percent in a hospital. Just 11 percent died at home, though that is where most people prefer to die, studies repeatedly show.

Among those who didn’t use the S.N.F. benefit, more than 40 percent died at home.

In effect, nursing homes were providing end-of-life care, expensively and probably not so well, for almost a third of the elderly population.

The skilled-nursing facility benefit, Dr. Aragon pointed out in an interview, is meant to provide rehabilitation. “The hope is that someone will get stronger and go home,” she said.

Sometimes, of course, that is what happens.

“What we may be missing is that this patient is on an end-of-life trajectory,” she continued. “Maybe they can’t get stronger.”

Moreover, Dr. Aragon pointed out, nursing homes often have financial incentives to keep re-hospitalizing patients. After three days in a hospital, the skilled-nursing facility benefit starts anew, and it reimburses at a higher level than Medicaid, which pays for most nursing home care.

Because this unhappy choice between hospice care and nursing home reimbursement reflects federal policy, there may be little that individual families can do. If physicians are willing to honestly discuss their patients’ prognosis, to assess whether a nursing home stay will lead to rehabilitation or whether it is where a patient will likely die, sooner rather than later, families may have some personal options.

If they knew that death was likely within a few months, they might try to provide care at home with hospice help for that limited time, difficult as that is. Or they might be able to muster enough money to pay for a few months in a nursing home, so that their parent can be a resident and still receive hospice care.

But these are still lousy choices. “Palliative care should be part of nursing home care,” said Alexander K. Smith, the study’s senior author and a palliative care specialist at the University of California, San Francisco. “And that regulation that prevents concurrent use of the S.N.F. benefit and hospice isn’t in the interest of patients and families.”

Coming up in a future post: Experimenting with a concurrent-coverage option.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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The New Old Age Blog: Forced to Choose: Nursing Home vs. Hospice

An older person, someone who will die within six months, leaves a hospital. Where does she go?

Almost a third of the time, according to a recent study from the University of California, San Francisco, records show she takes advantage of Medicare’s skilled-nursing facility benefit and enters a nursing home. But is that the best place for end-of-life care?

In terms of monitoring her vital signs and handling IVs — the round-the-clock nursing care the skilled-nursing facility benefit is designed to provide — maybe so. But for treating end-of-life symptoms like pain and shortness of breath, for providing spiritual support for her and her family, for palliative care that helps her through the ultimate transition – hospice is the acknowledged expert.

She could receive hospice care, also covered by Medicare, while in the nursing home. But since Medicare only rarely reimburses for both hospice and the skilled-nursing facility benefit at the same time, this hypothetical patient and her family face a financial bind. If she opts for the hospice benefit, which does not include room and board at the nursing home, then she will be on the hook for hundreds of dollars a day to remain in the facility.

She could use the hospice benefit at home, of course. But, “we know these patients are medically complex,” said Katherine Aragon, lead author of the study in The Archives of Internal Medicine, and now a palliative care specialist at Lawrence General Hospital in Massachusetts. “And we know that taking care of someone near the end of life can be very demanding, hard for families to manage at home.” And that assumes the patient has a family or a home.

For some patients, a nursing home, though possibly dreaded, is the only place that can provide 24/7 care.

But if she uses the skilled-nursing facility benefit to pay for room and board in a facility, she probably has to forgo hospice. (The exception: if she was hospitalized for something unrelated to her hospice diagnosis. If she has cancer, then trips and breaks a hip, she can have both nursing home coverage and hospice. If cancer itself caused the bone to fracture, no dice.)

Let’s acknowledge that these are lousy choices.

The study, using data from the National Health and Retirement Study from 1994 through 2007, looked at more than 5,000 people who initially lived in the community – that is, not in a facility. About 30 percent used the skilled-nursing facility benefit during the final six months of life; those people were likely to be over 85 and family members said, after their deaths, that they had expected them to die soon. (The benefit is commonly referred to as S.N.F., which people in the field pronounce as “sniff”).

The choice to use S.N.F. had ongoing repercussions. Almost 43 percent of those who used it died in a nursing home and almost 40 percent in a hospital. Just 11 percent died at home, though that is where most people prefer to die, studies repeatedly show.

Among those who didn’t use the S.N.F. benefit, more than 40 percent died at home.

In effect, nursing homes were providing end-of-life care, expensively and probably not so well, for almost a third of the elderly population.

The skilled-nursing facility benefit, Dr. Aragon pointed out in an interview, is meant to provide rehabilitation. “The hope is that someone will get stronger and go home,” she said.

Sometimes, of course, that is what happens.

“What we may be missing is that this patient is on an end-of-life trajectory,” she continued. “Maybe they can’t get stronger.”

Moreover, Dr. Aragon pointed out, nursing homes often have financial incentives to keep re-hospitalizing patients. After three days in a hospital, the skilled-nursing facility benefit starts anew, and it reimburses at a higher level than Medicaid, which pays for most nursing home care.

Because this unhappy choice between hospice care and nursing home reimbursement reflects federal policy, there may be little that individual families can do. If physicians are willing to honestly discuss their patients’ prognosis, to assess whether a nursing home stay will lead to rehabilitation or whether it is where a patient will likely die, sooner rather than later, families may have some personal options.

If they knew that death was likely within a few months, they might try to provide care at home with hospice help for that limited time, difficult as that is. Or they might be able to muster enough money to pay for a few months in a nursing home, so that their parent can be a resident and still receive hospice care.

But these are still lousy choices. “Palliative care should be part of nursing home care,” said Alexander K. Smith, the study’s senior author and a palliative care specialist at the University of California, San Francisco. “And that regulation that prevents concurrent use of the S.N.F. benefit and hospice isn’t in the interest of patients and families.”

Coming up in a future post: Experimenting with a concurrent-coverage option.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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High & Low Finance: A Clash of Auditors in H.P. Deal and Loss

The battle over Hewlett-Packard’s claim that it was bamboozled when it bought Autonomy, a British software company, has been long on angry rhetoric and short on details about the accounting that was supposedly wrong and led to an $8.8 billion write-down.

But the eternal question asked whenever a fraud surfaces — “Where were the auditors?” — does have an answer in this case.

They were everywhere.

They were consulting. They were advising, according to one account, on strategies for “optimizing” revenue. They were investigating whether books were cooked, and they were signing off on audits approving the books that are now alleged to have been cooked. They were offering advice on executive pay. There are four major accounting firms, and each has some involvement.

Herewith a brief summary of the Autonomy dispute:

Hewlett-Packard, a computer maker that in recent years has gone from one stumble to another, bought Autonomy last year. The British company’s accounting had long been the subject of harsh criticism from some short-sellers, but H.P. evidently did not care. The $11 billion deal closed in October 2011.

Last week, H.P. said Autonomy had been cooking its books in a variety of ways. Mike Lynch, who founded Autonomy and was fired by H.P. this year, says the company’s books were fine. If the company has lost value, he says, it is because of H.P.’s mismanagement.

Autonomy was audited by the British arm of Deloitte. H.P., which is audited by Ernst & Young, hired KPMG to perform due diligence in connection with the acquisition — due diligence that presumably found no big problems with the books.

That covered three of the four big firms, so it should be no surprise that the final one, PricewaterhouseCoopers, was brought in to conduct a forensic investigation after an unnamed whistle-blower told H.P. that the books were not kosher. H.P. says the PWC investigation found “serious accounting improprieties, misrepresentation and disclosure failures.”

That would seem to make the Big Four tally two for Autonomy and two for H.P., or at least it would when Ernst approves H.P.’s annual report including the write-down.

But KPMG wants it known that it “was not engaged by H.P. to perform any audit work on this matter. The firm’s only role was to provide a limited set of non-audit-related services.” KPMG won’t say what those services were, but states, “We can say with confidence that we acted responsibly and with integrity.’

Deloitte did much more for Autonomy than audit its books, perhaps taking advantage of British rules, which are more relaxed about potential conflicts of interest than are American regulations enacted a decade ago in the Sarbanes-Oxley law. In 2010, states the company’s annual report, 44 percent of the money paid to Deloitte by Autonomy was for nonaudit services. Some of the money went for “advice in relation to remuneration,” which presumably means consultations on how much executives should be paid.

The consulting arms of the Big Four also have relationships that can be complicated. At an auditing conference this week at New York University, Francine McKenna of Forbes.com noted that Deloitte was officially a platinum-level “strategic alliance technology implementation partner” of H.P. and said she had learned of “at least two large client engagements where Autonomy and Deloitte Consulting worked together before the acquisition.” A Deloitte spokeswoman did not comment on that report.

To an outsider, making sense of this brouhaha is not easy. In a normal accounting scandal, if there is such a thing, the company restates its earnings and details how revenue was inflated or costs hidden. That has not happened here, and it may never happen. There is not even an accusation of how much Autonomy inflated its profits, but if there were, it would be a very small fraction of the $8.8 billion write-off that H.P. took. Autonomy never reported earning $1 billion in a year.

That $8.8 billion represents a write-off of much of the good will that H.P. booked when it made the deal, based on the conclusion that Autonomy was not worth nearly as much as it had paid. It says more than $5 billion of that relates to the accounting irregularities, with the rest reflecting H.P.’s low stock price and “headwinds against anticipated synergies and marketplace performance,” whatever that might mean.

Some of the accounting accusations relate to how Autonomy booked expenses. The H.P. version is that the British company made sales of hardware — personal computers it bought and resold — look like sales of valuable software. It hid some costs as marketing expenses when they should have been reported as costs of goods sold.

All that, if true, would inflate operating profit margins and growth rates for the most important part of the business. But it would not change net earnings.

Floyd Norris comments on finance and the economy at nytimes.com/economix.

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General Assembly Grants Palestine Upgraded Status in U.N.

Damon Winter/The New York Times

The Palestinian Authority president, Mahmoud Abbas, center, was congratulated by Turkey’s foreign minister, Ahmet Davutoglu. More Photos »

UNITED NATIONS — More than 130 countries voted on Thursday to upgrade Palestine to a nonmember observer state of the United Nations, a triumph for Palestinian diplomacy and a sharp rebuke to the United States and Israel.

But the vote, at least for now, did little to bring either the Palestinians or the Israelis closer to the goal they claim to seek: two states living side by side, or increased Palestinian unity. Israel and the militant group Hamas both responded critically to the day’s events, though for different reasons.

The new status will give the Palestinians more tools to challenge Israel in international legal forums for its occupation activities in the West Bank, including settlement-building, and it helped bolster the Palestinian Authority, weakened after eight days of battle between its rival Hamas and Israel.

But even as a small but determined crowd of 2,000 celebrated in central Ramallah in the West Bank, waving flags and dancing, there was an underlying sense of concerned resignation.

“I hope this is good,” said Munir Shafie, 36, an electrical engineer who was there. “But how are we going to benefit?”

Still, the General Assembly vote — 138 countries in favor, 9 opposed and 41 abstaining — showed impressive backing for the Palestinians at a difficult time. It was taken on the 65th anniversary of the vote to divide the former British mandate of Palestine into two states, one Jewish and one Arab, a vote Israel considers the international seal of approval for its birth.

The past two years of Arab uprisings have marginalized the Palestinian cause to some extent as nations that focused their political aspirations on the Palestinian struggle have turned inward. The vote on Thursday, coming so soon after the Gaza fighting, put the Palestinians again — if briefly, perhaps — at the center of international discussion.

“The question is, where do we go from here and what does it mean?” Salam Fayyad, the Palestinian prime minister, who was in New York for the vote, said in an interview. “The sooner the tough rhetoric of this can subside and the more this is viewed as a logical consequence of many years of failure to move the process forward, the better.” He said nothing would change without deep American involvement.

President Mahmoud Abbas of the Palestinian Authority, speaking to the assembly’s member nations, said, “The General Assembly is called upon today to issue a birth certificate of the reality of the state of Palestine,” and he condemned what he called Israeli racism and colonialism. His remarks seemed aimed in part at Israel and in part at Hamas. But both quickly attacked him for the parts they found offensive.

“The world watched a defamatory and venomous speech that was full of mendacious propaganda against the Israel Defense Forces and the citizens of Israel,” Prime Minister Benjamin Netanyahu of Israel responded. “Someone who wants peace does not talk in such a manner.”

While Hamas had officially backed the United Nations bid of Mr. Abbas, it quickly criticized his speech because the group does not recognize Israel.

“There are controversial issues in the points that Abbas raised, and Hamas has the right to preserve its position over them,” said Salah al-Bardaweel, a spokesman for Hamas in Gaza, on Thursday.

“We do not recognize Israel, nor the partition of Palestine, and Israel has no right in Palestine,” he added. “Getting our membership in the U.N. bodies is our natural right, but without giving up any inch of Palestine’s soil.”

Israel’s ambassador to the United Nations, Ron Prosor, spoke after Mr. Abbas and said he was concerned that the Palestinian Authority failed to recognize Israel for what it is.

“Three months ago, Israel’s prime minister stood in this very hall and extended his hand in peace to President Abbas,” Mr. Prosor said. “He reiterated that his goal was to create a solution of two states for two peoples, where a demilitarized Palestinian state will recognize Israel as a Jewish state.

“That’s right. Two states for two peoples. In fact, President Abbas, I did not hear you use the phrase ‘two states for two peoples’ this afternoon. In fact, I have never heard you say the phrase ‘two states for two peoples’ because the Palestinian leadership has never recognized that Israel is the nation-state of the Jewish people.”

The Israelis also say that the fact that Mr. Abbas is not welcome in Gaza, the Palestinian coastal enclave run by Hamas, from which he was ejected five years ago, shows that there is no viable Palestinian leadership living up to its obligations now.

Jennifer Steinhauer contributed reporting from Washington, Isabel Kershner from Jerusalem, and Khaled Abu Aker from Ramallah, West Bank.

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The Next War: In Federal Budget Cutting, F-35 Fighter Jet Is at Risk

Luke Sharrett for The New York Times

Vice Adm. David Venlet was named to lead the Joint Strike Fighter program in 2010 after problems had left it behind schedule and over budget.

LEXINGTON PARK, Md. — The Marine version of the F-35 Joint Strike Fighter, already more than a decade in the making, was facing a crucial question: Could the jet, which can soar well past the speed of sound, land at sea like a helicopter?

Luke Sharrett for The New York Times

An F-35B, the Marine Corps version of the Joint Strike Fighter.

On an October day last year, with Lt. Col. Fred Schenk at the controls, the plane glided toward a ship off the Atlantic coast and then, its engine rotating straight down, descended gently to the deck at seven feet a second.

There were cheers from the ship’s crew members, who “were all shaking my hands and smiling,” Colonel Schenk recalled.

The smooth landing helped save that model and breathed new life into the huge F-35 program, the most expensive weapons system in military history. But while Pentagon officials now say that the program is making progress, it begins its 12th year in development years behind schedule, troubled with technological flaws and facing concerns about its relatively short flight range as possible threats grow from Asia.

With a record price tag — potentially in the hundreds of billions of dollars — the jet is likely to become a target for budget cutters. Reining in military spending is on the table as President Obama and Republican leaders in Congress look for ways to avert a fiscal crisis. But no matter what kind of deal is reached in the next few weeks, military analysts expect the Pentagon budget to decline in the next decade as the war in Afghanistan ends and the military is required to do its part to reduce the federal debt.

Behind the scenes, the Pentagon and the F-35’s main contractor, Lockheed Martin, are engaged in a conflict of their own over the costs. The relationship “is the worst I’ve ever seen, and I’ve been in some bad ones,” Maj. Gen. Christopher Bogdan of the Air Force, a top program official, said in September. “I guarantee you: we will not succeed on this if we do not get past that.”

In a battle that is being fought on other military programs as well, the Pentagon has been pushing Lockheed to cut costs much faster while the company is fighting to hold onto a profit. “Lockheed has seemed to be focused on short-term business goals,” Frank Kendall, the Pentagon’s top weapons buyer, said this month. “And we’d like to see them focus more on execution of the program and successful delivery of the product.”

The F-35 was conceived as the Pentagon’s silver bullet in the sky — a state-of-the art aircraft that could be adapted to three branches of the military, with advances that would easily overcome the defenses of most foes. The radar-evading jets would not only dodge sophisticated antiaircraft missiles, but they would also give pilots a better picture of enemy threats while enabling allies, who want the planes, too, to fight more closely with American forces.

But the ambitious aircraft instead illustrates how the Pentagon can let huge and complex programs veer out of control and then have a hard time reining them in. The program nearly doubled in cost as Lockheed and the military’s own bureaucracy failed to deliver on the most basic promise of a three-in-one jet that would save taxpayers money and be served up speedily.

Lockheed has delivered 41 planes so far for testing and initial training, and Pentagon leaders are slowing purchases of the F-35 to fix the latest technical problems and reduce the immediate costs. A helmet for pilots that projects targeting data onto its visor is too jittery to count on. The tail-hook on the Navy jet has had trouble catching the arresting cable, meaning that version cannot yet land on carriers. And writing and testing the millions of lines of software needed by the jets is so daunting that General Bogdan said, “It scares the heck out of me.”

With all the delays — full production is not expected until 2019 — the military has spent billions to extend the lives of older fighters and buy more of them to fill the gap. At the same time, the cost to build each F-35 has risen to an average of $137 million from $69 million in 2001.

The jets would cost taxpayers $396 billion, including research and development, if the Pentagon sticks to its plan to build 2,443 by the late 2030s. That would be nearly four times as much as any other weapons system and two-thirds of the $589 billion the United States has spent on the war in Afghanistan. The military is also desperately trying to figure out how to reduce the long-term costs of operating the planes, now projected at $1.1 trillion.

“The plane is unaffordable,” said Winslow T. Wheeler, an analyst at the Project on Government Oversight, a nonprofit group in Washington.

Todd Harrison, an analyst at the Center for Strategic and Budgetary Assessments, a research group in Washington, said Pentagon officials had little choice but to push ahead, especially after already spending $65 billion on the fighter. “It is simultaneously too big to fail and too big to succeed,” he said. “The bottom line here is that they’ve crammed too much into the program. They were asking one fighter to do three different jobs, and they basically ended up with three different fighters.”

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The New Old Age Blog: New Help for Hoarders

There were times, Sandra Stark remembers, when she couldn’t use her kitchen or sit on her sofa. Her collections — figurines, vases, paperweights — had overtaken every closet, drawer and surface. Stacks of clothing and old magazines added to the clutter.

Her daughters came in and threw everything away — to Ms. Stark’s horror — but a year later her home was again barely navigable. “I couldn’t throw out my garbage,” she said. “I put it in plastic bags, but I couldn’t take it out.”

A drop-in support group sponsored by the Mental Health Association of San Francisco helped her begin to control her hoarding behavior, and she has made considerable headway. “My bedroom is still a work in progress,” said Ms. Stark, 67. “But I can cook again.”

She has become a trained peer responder who works with others with this disorder. Many of the Mental Health Association’s clients are older adults: A woman in her 70s occupies one small room because the rest of her spacious house — leaking and mildewed — is filled with stuff she can’t discard. An 87-year-old, a compulsive thrift-store shopper, faces eviction because the city health department says she has created a safety hazard. “I’ll say, ‘Of these dozen black leather coats, pick two,’” Ms. Stark said, mapping her strategy to help keep the woman in her home.

Researchers are not sure if hoarding intensifies with age, but the problems it creates certainly do. “The older you get, the more stuff you’ve been able to accumulate,” said Randy Frost, co-author of the book “Stuff” and a Smith College psychologist. “And older people are less physically able to deal with it.” They are more prone to falls as they try to maneuver between piles of possessions and in a crisis, emergency crews may have trouble even entering their dwellings.

When I last wrote about hoarding almost three years ago (uncorking a wave of readers’ lamentation), I couldn’t offer much in the way of help except to steer people to the OCD Foundation. Though hoarding may not be a form of obsessive-compulsive disorder, its site remains useful.

At the time, experts knew what didn’t solve the problem, namely psychoactive drugs or “dumpster therapy,” in which well-meaning friends or family toss hoarders’ possessions, in a temporary fix that doesn’t change their behavior. But researchers were only starting to figure out what did work.

“This is an area in which there haven’t been a lot of answers,” said Eduardo Vega, executive director of the Mental Health Association of San Francisco. Now, “there’s a lot more hope and good will.”

Across the country, for example, cities, counties and states have formed about 80 hoarding task forces so that housing and health departments, senior service agencies, law enforcement and emergency units can coordinate their responses.

On the mental health front, the revised Diagnostic and Statistical Manual V is scheduled for publication in the spring, and many expect it will recognize hoarding as a distinct disorder with diagnostic criteria and a numeric code. That will make psychologists and other professionals more aware of the problem and, Mr. Vega said, “it will be easier to get insurers and providers to pay for treatment.”

Increasingly, there is treatment. Researchers have published studies showing that cognitive behavioral therapy can help, by encouraging people to reevaluate their attachment to possessions and supporting their decisions to start discarding.

Among patients in therapy groups, Dr. Frost has shown, 70 to 80 percent showed some improvement, he said. “That doesn’t mean they’re freed of symptoms, but their lives are improved and the behavior significantly reduced.”

Questions remain; several published studies use small samples that are heavily comprised of females, though hoarding may be more common among men. It is not clear, Dr. Frost said, whether cognitive therapy is as effective among older adults. And it is easier to find an individual therapist or a group in major cities than elsewhere. (Here’s a locator.)

But Dr. Frost and his co-authors have published a workbook called “Buried in Treasures,” along with a free facilitator’s guide, that allows people with hoarding disorders to form their own 15-session action workshops, led by peers rather than professionals. That approach, too, has brought measurable improvement (when used in groups, not individually), a study shows. “Here’s a way people can start working on this on their own,” Dr. Frost said.

Diagnostic criteria, treatment centers, workbooks, published research — all this is more than mental health professionals could offer years back. Still, compulsive hoarding remains a stubborn problem, a safety risk for older people and a heartache for their families.

“It’s really difficult for adult children,” who worry about their parents, but can’t induce them to change, Dr. Frost said. “There may be a history of animosity. Many report they grew up feeling their hoarding parents cared more about their possessions than about them.” The children, young or grown, could probably use a support group, too.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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The New Old Age Blog: New Help for Hoarders

There were times, Sandra Stark remembers, when she couldn’t use her kitchen or sit on her sofa. Her collections — figurines, vases, paperweights — had overtaken every closet, drawer and surface. Stacks of clothing and old magazines added to the clutter.

Her daughters came in and threw everything away — to Ms. Stark’s horror — but a year later her home was again barely navigable. “I couldn’t throw out my garbage,” she said. “I put it in plastic bags, but I couldn’t take it out.”

A drop-in support group sponsored by the Mental Health Association of San Francisco helped her begin to control her hoarding behavior, and she has made considerable headway. “My bedroom is still a work in progress,” said Ms. Stark, 67. “But I can cook again.”

She has become a trained peer responder who works with others with this disorder. Many of the Mental Health Association’s clients are older adults: A woman in her 70s occupies one small room because the rest of her spacious house — leaking and mildewed — is filled with stuff she can’t discard. An 87-year-old, a compulsive thrift-store shopper, faces eviction because the city health department says she has created a safety hazard. “I’ll say, ‘Of these dozen black leather coats, pick two,’” Ms. Stark said, mapping her strategy to help keep the woman in her home.

Researchers are not sure if hoarding intensifies with age, but the problems it creates certainly do. “The older you get, the more stuff you’ve been able to accumulate,” said Randy Frost, co-author of the book “Stuff” and a Smith College psychologist. “And older people are less physically able to deal with it.” They are more prone to falls as they try to maneuver between piles of possessions and in a crisis, emergency crews may have trouble even entering their dwellings.

When I last wrote about hoarding almost three years ago (uncorking a wave of readers’ lamentation), I couldn’t offer much in the way of help except to steer people to the OCD Foundation. Though hoarding may not be a form of obsessive-compulsive disorder, its site remains useful.

At the time, experts knew what didn’t solve the problem, namely psychoactive drugs or “dumpster therapy,” in which well-meaning friends or family toss hoarders’ possessions, in a temporary fix that doesn’t change their behavior. But researchers were only starting to figure out what did work.

“This is an area in which there haven’t been a lot of answers,” said Eduardo Vega, executive director of the Mental Health Association of San Francisco. Now, “there’s a lot more hope and good will.”

Across the country, for example, cities, counties and states have formed about 80 hoarding task forces so that housing and health departments, senior service agencies, law enforcement and emergency units can coordinate their responses.

On the mental health front, the revised Diagnostic and Statistical Manual V is scheduled for publication in the spring, and many expect it will recognize hoarding as a distinct disorder with diagnostic criteria and a numeric code. That will make psychologists and other professionals more aware of the problem and, Mr. Vega said, “it will be easier to get insurers and providers to pay for treatment.”

Increasingly, there is treatment. Researchers have published studies showing that cognitive behavioral therapy can help, by encouraging people to reevaluate their attachment to possessions and supporting their decisions to start discarding.

Among patients in therapy groups, Dr. Frost has shown, 70 to 80 percent showed some improvement, he said. “That doesn’t mean they’re freed of symptoms, but their lives are improved and the behavior significantly reduced.”

Questions remain; several published studies use small samples that are heavily comprised of females, though hoarding may be more common among men. It is not clear, Dr. Frost said, whether cognitive therapy is as effective among older adults. And it is easier to find an individual therapist or a group in major cities than elsewhere. (Here’s a locator.)

But Dr. Frost and his co-authors have published a workbook called “Buried in Treasures,” along with a free facilitator’s guide, that allows people with hoarding disorders to form their own 15-session action workshops, led by peers rather than professionals. That approach, too, has brought measurable improvement (when used in groups, not individually), a study shows. “Here’s a way people can start working on this on their own,” Dr. Frost said.

Diagnostic criteria, treatment centers, workbooks, published research — all this is more than mental health professionals could offer years back. Still, compulsive hoarding remains a stubborn problem, a safety risk for older people and a heartache for their families.

“It’s really difficult for adult children,” who worry about their parents, but can’t induce them to change, Dr. Frost said. “There may be a history of animosity. Many report they grew up feeling their hoarding parents cared more about their possessions than about them.” The children, young or grown, could probably use a support group, too.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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Gadgetwise Blog: Q&A: Preventing Unintended Mobile Purchases

Is there a way to keep children from buying stuff in the Google Play Store when they are entertaining themselves with my Android phone?

Smartphones are great for temporarily distracting fidgety children. If you would rather not get a surprise in your credit card bill because little fingers wandered into the Google Play Store, you can set the phone to require a PIN (personal identification number) before apps and games can be purchased. You need version 3.1 or later of the Google Play Store on the phone.

To set up a PIN, open the phone’s Google Play Store app. Press the Menu button and then Settings. Select the “Set or change PIN” option and enter the numeric code you want to use. Tap O.K. and re-enter the number to confirm it. Next, tap the box next to “Use PIN for purchases.”

The PIN will now be required to make a purchase from the Google Play Store. Google has instructions if you need to change, remove or reset your PIN later.

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U.S. Is Weighing Stronger Action in Syrian Conflict

Francisco Leong/Agence France-Presse — Getty Images

Rebels in northern Syria celebrated on Wednesday next to what was reported to be a government fighter jet.

WASHINGTON — The Obama administration, hoping that the conflict in Syria has reached a turning point, is considering deeper intervention to help push President Bashar al-Assad from power, according to government officials involved in the discussions.

While no decisions have been made, the administration is considering several alternatives, including directly providing arms to some opposition fighters.

The most urgent decision, likely to come next week, is whether NATO should deploy surface-to-air missiles in Turkey, ostensibly to protect that country from Syrian missiles that could carry chemical weapons. The State Department spokeswoman, Victoria Nuland, said Wednesday that the Patriot missile system would not be “for use beyond the Turkish border.”

But some strategists and administration officials believe that Syrian Air Force pilots might fear how else the missile batteries could be used. If so, they could be intimidated from bombing the northern Syrian border towns where the rebels control considerable territory. A NATO survey team is in Turkey, examining possible sites for the batteries.

Other, more distant options include directly providing arms to opposition fighters rather than only continuing to use other countries, especially Qatar, to do so. A riskier course would be to insert C.I.A. officers or allied intelligence services on the ground in Syria, to work more closely with opposition fighters in areas that they now largely control.

Administration officials discussed all of these steps before the presidential election. But the combination of President Obama’s re-election, which has made the White House more willing to take risks, and a series of recent tactical successes by rebel forces, one senior administration official said, “has given this debate a new urgency, and a new focus.”

The outcome of the broader debate about how heavily America should intervene in another Middle Eastern conflict remains uncertain. Mr. Obama’s record in intervening in the Arab Spring has been cautious: While he joined in what began as a humanitarian effort in Libya, he refused to put American military forces on the ground and, with the exception of a C.I.A. and diplomatic presence, ended the American role as soon as Col. Muammar el-Qaddafi was toppled.

In the case of Syria, a far more complex conflict than Libya’s, some officials continue to worry that the risks of intervention — both in American lives and in setting off a broader conflict, potentially involving Turkey — are too great to justify action. Others argue that more aggressive steps are justified in Syria by the loss in life there, the risks that its chemical weapons could get loose, and the opportunity to deal a blow to Iran’s only ally in the region. The debate now coursing through the White House, the Pentagon, the State Department and the C.I.A. resembles a similar one among America’s main allies.

“Look, let’s be frank, what we’ve done over the last 18 months hasn’t been enough,” Britain’s prime minister, David Cameron, said three weeks ago after visiting a Syrian refugee camp in Jordan. “The slaughter continues, the bloodshed is appalling, the bad effects it’s having on the region, the radicalization, but also the humanitarian crisis that is engulfing Syria. So let’s work together on really pushing what more we can do.” Mr. Cameron has discussed those options directly with Mr. Obama, White House officials say.

France and Britain have recognized a newly formed coalition of opposition groups, which the United States helped piece together. So far, Washington has not done so.

American officials and independent specialists on Syria said that the administration was reviewing its Syria policy in part to gain credibility and sway with opposition fighters, who have seized key Syrian military bases in recent weeks.

“The administration has figured out that if they don’t start doing something, the war will be over and they won’t have any influence over the combat forces on the ground,” said Jeffrey White, a former Defense Intelligence Agency intelligence officer and specialist on the Syria military. “They may have some influence with various political groups and factions, but they won’t have influence with the fighters, and the fighters will control the territory.”

Jessica Brandt contributed reporting from Cambridge, Mass.

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California Shows Signs of Resurgence

Sam Hodgson/Bloomberg News

Prosperous coastal places like La Jolla, here, are better off than the state as a whole; many inland areas still have high jobless rates.

LOS ANGELES — After nearly five years of brutal economic decline, government retrenchment and a widespread loss of confidence in its future, California is showing the first signs of a rebound. There is evidence of job growth, economic stability, a resurgent housing market and rising spirits in a state that was among the worst hit by the recession.

California reported a 10.1 percent unemployment rate last month, down from 11.5 percent in October 2011 and the lowest since February 2009. In September, California had its biggest month-to-month drop in unemployment in the 36 years the state has collected statistics, from 10.6 percent to 10.2 percent, though the state still has the third-highest jobless rate in the nation.

The housing market, whose collapse in a storm of foreclosures helped worsen the economic decline, has snapped back in many, though not all, parts of the state. Houses are sitting on the market for a shorter time and selling at higher prices, and new home construction is rising. Home sales rose 25 percent in Southern California in October compared with a year earlier.

After years of spending cuts and annual state budget deficits larger than the entire budgets of some states, this month the independent California Legislative Analyst’s Office projected a deficit for next year of $1.9 billion — down from $25 billion at one point — and said California might post a $1 billion surplus in 2014, even accounting for the tendency of these projections to vary markedly from year to year.

A reason for the change, in addition to a series of deep budget cuts in recent years, was voter approval of Proposition 30, promoted by Gov. Jerry Brown to raise taxes temporarily to avoid up to $6 billion in education cuts.

“The state’s economic recovery, prior budget cuts and the additional, temporary taxes provided by Proposition 30 have combined to bring California to a promising moment: the possible end of a decade of acute state budget challenges,” the report said. “Our economic and budgetary forecast indicates that California’s leaders face a dramatically smaller budget problem in 2013-14.”

And 38 percent of Californians say the state is heading in the right direction, according to a survey this month by U.S.C. Dornsife/Los Angeles Times. For most places, that figure would seem dismal. But it is double what it was 13 months ago.

California’s recovery echoes a rebound across much of the country; the state suffered not only one of the longest downturns but also one of the most severe. Economists say the turnaround, should it continue, is a positive harbinger for the nation, given the size and diversity of the state’s economy.

Democrats here have been quick to argue that the improvements in fiscal conditions that the state is now projecting after voters approved the temporary tax increase may embolden other states, and Congress, to raise some taxes rather than turn to a new round of cuts.

Yet California still faces major problems. The economic recovery is hardly uniform. Central California and the Inland Empire — the suburban sprawl east of Los Angeles — continue to stagger under the collapse of the construction market, and some economists wonder if they will ever join the coastal cities on the prosperity train. Cities, most recently San Bernardino, are facing bankruptcy, and public employee pension costs loom as a major threat to the state budget and those of many municipalities, including Los Angeles.

A federal report this month said that by some measures, California has the worst poverty in the nation. The river of people coming west in search of the economic dream, traditionally an economic and creative driver, has slowed to a crawl.

Still, the fear among many Californians that the bottom had fallen out appears to be fading. Economists said they were spotting many signs of incipient growth, including a surge in rental costs in the Bay Area, which suggests an influx of people looking for jobs.

“I think the state is turning a corner,” said Enrico Moretti, a professor of economics at the University of California, Berkeley. He said that the recovery was creating regional lines of economic demarcation — “We are going to see a more and more polarized state,” he said — but that over all, California was emerging from the recession.

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The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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The New Old Age Blog: Doctor's Orders? Another Test

It is no longer news that Americans, and older Americans in particular, get more routine screening tests than they need, more than are useful. Prostate tests for men over 75, annual Pap smears for women over 65 and colonoscopies for anyone over 75 — all are overused, large-scale studies have shown.

Now it appears that many older patients are also subjected to too-frequent use of the other kind of testing, diagnostic tests.

The difference, in brief: Screening tests are performed on people who are asymptomatic, who aren’t complaining of a health problem, as a way to detect incipient disease. We have heard for years that it is best to “catch it early” — “it” frequently being cancer — and though that turns out to be only sometimes true, we and our doctors often ignore medical guidelines and ongoing campaigns to limit and target screening tests.

Diagnostic tests, on the other hand, are meant to help doctors evaluate some symptom or problem. “You’re trying to figure out what’s wrong,” explained Gilbert Welch, a veteran researcher at the Dartmouth Institute for Health Policy and Clinical Practice.

For these tests, medical groups and task forces offer many fewer guidelines on who should get them and how often — there is not much evidence to go on — but there is general agreement that they are not intended for routine surveillance.

But a study using a random 5 percent sample of Medicare beneficiaries — nearly 750,000 of them — suggests that often, that is what’s happening.

“It begins to look like some of these tests are being routinely repeated, and it’s worrisome,” said Dr. Welch, lead author of the study just published in The Archives of Internal Medicine. “Some physicians are just doing them every year.”

He is talking about tests like echocardiography, or a sonogram of the heart. More than a quarter of the sample (28.5 percent) underwent this test between 2004 and 2006, and more than half of those patients (55 percent) had a repeat echocardiogram within three years, most commonly within a year of the first.

Other common tests were frequently repeated as well. Of patients who underwent an imaging stress test, using a treadmill or stationery bike (or receiving a drug) to make the heart work harder, nearly 44 percent had a repeat test within three years. So did about half of those undergoing pulmonary function tests and chest tomography, a CAT scan of the chest.

Cytoscopy (a procedure in which a viewing tube is inserted into the bladder) was repeated for about 41 percent of the patients, and endoscopy (a swallowed tube enters the esophagus and stomach) for more than a third.

Is this too much testing? Without evidence of how much it harms or helps patients, it is hard to say — but the researchers were startled by the extent of repetition. “It’s inconceivable that it’s all important,” Dr. Welch said. “Unfortunately, it looks like it’s important for doctors.”

The evidence for that? The study revealed big geographic differences in diagnostic testing. Looking at the country’s 50 largest metropolitan areas, it found that nearly half the sample’s patients in Miami had an echocardiogram between 2004 and 2006, and two thirds of them had another echocardiogram within three years — the highest rate in the nation.

In fact, for the six tests the study included, five were performed and repeated most often in Florida cities: Miami, Jacksonville and Orlando. “They’re heavily populated by physicians and they have a long history of being at the top of the list” of areas that do a lot of medical procedures and hospitalizations, Dr. Welch said.

But in Portland, Ore., where “the physician culture is very different,” only 17.5 percent of patients had an echocardiogram. The places most prone to testing were also the places with high rates of repeat testing. Portland, San Francisco and Sacramento had the lowest rates.

We often don’t think of tests as having a downside, but they do. “This is the way whole cascades can start that are hard to stop,” Dr. Welch said. “The more we subject ourselves, the more likely some abnormality shows up that may require more testing, some of which has unwanted consequences.”

Properly used, of course, diagnostic tests can provide crucial information for sick people. “But used without a good indication, they can stir up a hornet’s nest,” he said. And of course they cost Medicare a bundle.

An accompanying commentary, sounding distinctly exasperated, pointed out that efforts to restrain overtesting and overtreatment have continued for decades. The commentary called it “discouraging to contemplate fresh evidence by Welch et al of our failure to curb waste of health care resources.”

It is hard for laypeople to know when tests make sense, but clearly we need to keep track of those we and our family members have. That way, if the cardiologist suggests another echocardiogram, we can at least ask a few pointed questions:

“My father just had one six months ago. Is it necessary to have another so soon? What information do you hope to gain that you didn’t have last time? Will the results change the way we manage his condition?”

Questions are always a good idea. Especially in Florida.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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DealBook: Autonomy's Ex-Chief Calls on H.P. to Defend Claims

In the fight between Hewlett-Packard and the founder of its Autonomy unit, the gloves are well and truly off.

The former head of Autonomy, Mike Lynch, issued a public letter Tuesday that called on the board of H.P. to defend its claims of accounting fraud at the company. He argued that H.P. had instead mismanaged Autonomy since acquiring it last year.

Shortly afterward, H.P. defended its findings and said it looked forward to hearing Mr. Lynch testify about Autonomy’s accounting practices under oath. It also reiterated plans to seek legal remedies.

The battle ensures further controversy over Autonomy, the British software maker at the center of an $8.8 billion charge H.P. announced last week. Founded 16 years ago, Autonomy had grown into one of Britain’s biggest technology start-ups.

H.P. paid more than $10 billion for Autonomy in a deal many analysts criticized as overpriced. It now says that an internal investigation of Autonomy uncovered evidence of questionable sales and “outright misrepresentations” of its financial health.

Among the practices, H.P. says, were classifying hardware sales as software sales and booking revenue too early. It said in its response to Mr. Lynch that the matter was being investigated by the Justice Department, as well as by securities regulators in the United States and Britain.

But some analysts and accountants have questioned whether H.P. is overstating the effects of any accounting improprieties to write off as much of the acquisition as possible.

In his letter, Mr. Lynch reiterated his insistence that he knew of no wrongdoing at Autonomy, arguing that it followed British accounting guidelines and that auditors at Deloitte approved its financial statements. He has suggested that differences between British and American rules may have accounted for seemingly suspicious software transactions.

Mr. Lynch also sought to turn attention to what he said was H.P.’s mismanagement.

“Can H.P. really state that no part of the $5 billion write-down was, or should be, attributed to H.P.’s operational and financial mismanagement of Autonomy since the acquisition?” he wrote.

He argued that H.P.’s management oversaw Autonomy’s finances for more than a year and should have been able to detect any improprieties sooner. “Why did H.P. senior management apparently wait six months to inform its shareholders of the possibility of a material event related to Autonomy?” he asked.

An H.P. spokesman, Michael Thacker, wrote in an e-mailed statement that the company believed it had found “extensive evidence” pointing to an attempt to inflate Autonomy’s financial metrics. H.P. said last week that its inquiry, initiated by a senior financial official in the Autonomy division, took months to comb through years of financial data.

Mr. Thacker added, “We look forward to hearing Dr. Lynch and other former Autonomy employees answer questions under penalty of perjury.”

Open Letter to the Board of H.P.

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Puerto Rico Races to Rescue Its Pension Fund

Puerto Rico is fighting to stay afloat in a rising sea of debt.

Its economy is sputtering. Its population is shrinking. Its recent election is disputed. Its public pension fund is perilously low on cash. The American territory has just been through a brutal five-year recession, something not experienced in the United States as a whole since the 1930s.

Desperate to raise cash, Puerto Rican officials have been selling off anything they can: two toll roads and the main airport so far.

To bring in tax revenue, they are trying to lure people out of the underground economy. Coffee shops, hairdressers, even outdoor market stalls are being required to issue printed receipts with every sale. The receipts carry a lottery number, with a chance to win cars or cash, as an incentive to get shoppers to pay the island’s 7 percent sales tax.

Though many of Puerto Rico’s problems are reminiscent of Greece’s — tax noncompliance, a stagnant economy, years of issuing long-term debt to cover short-term payments — investors have had a nearly insatiable appetite for its bonds.

But now their support is dwindling. Some big investors are pruning their holdings. That is beginning to widen the cost of borrowing for Puerto Rico relative to other states and municipalities, which are benefiting from a big decline in borrowing costs. The interest rate its 30-year bonds now pay is about 2.5 percentage points higher than other municipal borrowers’, up from a difference of just 1.5 percentage points at the beginning of 2012, according to Municipal Market Data.

The possibility of a credit downgrade also hangs in the air, something that could lead to more selling.

“There is no specific event looming on the horizon,” said Alan Schankel, a managing director at Janney Capital Markets in Philadelphia. “But it’s a problem of immense magnitude, and it’s very challenging to sit here and see how they work their way out of it.”

Puerto Rico needs to be able to issue bonds at attractive rates to cover its short-term financing needs. Perhaps more important, it has to figure out how to salvage its retirement funds. After shortchanging them for years, it now has the weakest major public pension system in America.

The main fund, which serves about 250,000 government workers, past and present, is only 6 percent funded — a small percentage of what is considered the minimum needed for a marginally healthy pension plan — and could run out of money as soon as 2014. Another fund, for about 80,000 teachers, which is 20 percent funded, will last just a few years longer if nothing is done. Police officers and teachers in Puerto Rico have opted out of Social Security and rely entirely on their pensions.

“For now, I’m not totally shaken about the possibility of the fund going broke,” said Jorge Ramón Román, a 78-year-old retired instructor for the island’s Civil Air Patrol. “But I do fear for the future, when I’ll be an even older person, more infirm and with less of a pension.”

Héctor M. Mayol Kauffman, the executive director of the pension system, said it would be impossible to cut the benefits of people who are already retired, citing court precedent.

Puerto Rican officials were racing this fall to put together a rescue plan for the pension fund. Voters, though, pushed out Gov. Luis Fortuño, who had tried austerity measures that included cutting tens of thousands of government workers along with a revamping of the fund.

They elected Alejandro García Padilla, who promised to create 50,000 new jobs in the next 18 months. But the margin was razor-thin and Mr. Fortuño has requested a recount. Mr. García Padilla’s party had dropped out of the retirement overhaul effort, but the governor-elect says he will deal with the looming pension crisis with “diligence and promptness” and has put together a task force of economists and financial advisers.

“We will not leave retired government workers stranded at a bus stop in their older years,” he said.

Since the election, yields on the island’s 30-year bonds have continued to widen.

“I don’t think that there’s a default that’s about to happen, but a default isn’t the only bad thing that can happen when you’ve got bonds,” Mr. Schankel said. Puerto Rico’s bonds are just a notch or two above junk status. If they fall to that level, at least some institutions would be forced to sell, potentially setting off a chain reaction. And individual investors could get a jolt if they saw the value of their holdings fall. Many people own Puerto Rican debt without knowing it, through their mutual funds.

“The concern is that Puerto Rico is a systemic risk to the municipal bond market because it’s so widely held,” said Robert Donahue, a managing director with Municipal Market Advisors.

Rafael Matos contributed reporting from San Juan, P.R.

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The New Old Age Blog: New Efforts to Close Hospitals' Revolving Doors

In the past, the only thing a patient was sure to get after a hospital stay was a bill. But as Medicare cracks down on high readmission rates, hospitals are dispatching nurses, transportation, culturally specific diet tips, free medications and even bathroom scales to patients deemed at risk of relapsing.

Robert Wood Johnson University Hospital in New Brunswick, N.J., has nurses visit high-risk patients at their home within two days of leaving the hosital. Teresa De Peralta, a nurse practitioner who runs the program, said they frequently find that patients don’t realize a drug they were prescribed in the hospital does the same thing as one they have already been taking.

“When medications are changed, they don’t want to throw things out, they think it’s a waste,” Ms. De Peralta said. “We actually go through the cupboards and painstakingly write out in big letters what they should be taking during the day.”

Many hospital officials say their efforts to keep patients healthy after discharge have been spurred by new financial penalties Medicare started imposing in October on places with too many readmissions. Increasingly, hospitals are no longer leaving to patients the responsibility for setting up follow-up appointments or filling new prescriptions.

And hospitals are not assuming that personnel in nursing homes and other facilities know how to properly care for their patients and follow the hospital discharge instructions.

Patients taking the wrong dose or mixing medicines that react badly often end up back in the hospital. A survey of 377 elderly patients at Yale-New Haven Hospital, published this year in The Journal of General Internal Medicine, discovered that 81 percent of the patients either didn’t understand what all their prescriptions were for; were prescribed the wrong drug or the wrong dose; were taken off a drug they needed, or never picked up a new prescription.

Dr. Leora Horwitz, the study’s leader, said patients who were called a week after their discharge and were asked what changes to their medication they were supposed to make “overwhelmingly” couldn’t tell them.

A big part of reducing readmissions is making sure that patients understand early warning signs that their health is deteriorating. Sun Health Care Transitions, a foundation-supported program in Sun City, Ariz., gives scales to some patients with congestive heart failure because small weight gains indicate they are retaining water, a sign that their heart isn’t pumping adequately.

“We have them keep a log,” said Jennifer Drago, a Sun Health vice president. “We want them to be looking for a two-pound daily weight gain, or five pounds over the week.”

Patients whose weight creeps up are quickly sent back to their doctor. Debra Richards, director of case management at Banner Del E. Webb Medical Center, one of the hospitals Sun Health is assisting, said, “That program has helped us quite a bit.”

Shady Grove Adventist Hospital in Rockville, Md., has started taking patients’ cultural backgrounds into consideration when doling out advice about maintaining their health. For example, the hospital encourages Salvadoran patients to substitute olive oils for the palm oils their cuisine traditionally calls for, to roast or bake meat instead of frying it and to use sugar substitutes when making horchata, a popular Central American drink.

When Hackensack University Medical Center sent staff members to teach caregivers how to take care of their patients, one place “didn’t even know what a low-salt diet was,” even though that’s a critical part of keeping heart failure patients from retaining fluids, said Dr. Charles Riccobono, chief quality and safety officer at the New Jersey hospital.

Aurora Health Care, a Milwaukee-based health system, now places its own nurse practitioners in several nursing homes to watch over Aurora’s discharged patients. Aurora says readmission rates of those patients have decreased, in some months by as much as half.

Dr. Eric Coleman, a Denver geriatrician whose ideas on reducing readmissions have been adopted by a number of hospitals and Medicare, said that while some hospital changes are “exciting and new,” others are “relabeling old wine in new bottles.”

“Yesterday we had ‘discharge planning’ and today we have a ‘rapid response transition team,’ and content-wise they’re doing the same thing,” Dr. Coleman said. “But it’s a nice thing to report out to the board of trustees.”

Jordan Rau is a reporter for Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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The New Old Age Blog: New Efforts to Close Hospitals' Revolving Doors

In the past, the only thing a patient was sure to get after a hospital stay was a bill. But as Medicare cracks down on high readmission rates, hospitals are dispatching nurses, transportation, culturally specific diet tips, free medications and even bathroom scales to patients deemed at risk of relapsing.

Robert Wood Johnson University Hospital in New Brunswick, N.J., has nurses visit high-risk patients at their home within two days of leaving the hosital. Teresa De Peralta, a nurse practitioner who runs the program, said they frequently find that patients don’t realize a drug they were prescribed in the hospital does the same thing as one they have already been taking.

“When medications are changed, they don’t want to throw things out, they think it’s a waste,” Ms. De Peralta said. “We actually go through the cupboards and painstakingly write out in big letters what they should be taking during the day.”

Many hospital officials say their efforts to keep patients healthy after discharge have been spurred by new financial penalties Medicare started imposing in October on places with too many readmissions. Increasingly, hospitals are no longer leaving to patients the responsibility for setting up follow-up appointments or filling new prescriptions.

And hospitals are not assuming that personnel in nursing homes and other facilities know how to properly care for their patients and follow the hospital discharge instructions.

Patients taking the wrong dose or mixing medicines that react badly often end up back in the hospital. A survey of 377 elderly patients at Yale-New Haven Hospital, published this year in The Journal of General Internal Medicine, discovered that 81 percent of the patients either didn’t understand what all their prescriptions were for; were prescribed the wrong drug or the wrong dose; were taken off a drug they needed, or never picked up a new prescription.

Dr. Leora Horwitz, the study’s leader, said patients who were called a week after their discharge and were asked what changes to their medication they were supposed to make “overwhelmingly” couldn’t tell them.

A big part of reducing readmissions is making sure that patients understand early warning signs that their health is deteriorating. Sun Health Care Transitions, a foundation-supported program in Sun City, Ariz., gives scales to some patients with congestive heart failure because small weight gains indicate they are retaining water, a sign that their heart isn’t pumping adequately.

“We have them keep a log,” said Jennifer Drago, a Sun Health vice president. “We want them to be looking for a two-pound daily weight gain, or five pounds over the week.”

Patients whose weight creeps up are quickly sent back to their doctor. Debra Richards, director of case management at Banner Del E. Webb Medical Center, one of the hospitals Sun Health is assisting, said, “That program has helped us quite a bit.”

Shady Grove Adventist Hospital in Rockville, Md., has started taking patients’ cultural backgrounds into consideration when doling out advice about maintaining their health. For example, the hospital encourages Salvadoran patients to substitute olive oils for the palm oils their cuisine traditionally calls for, to roast or bake meat instead of frying it and to use sugar substitutes when making horchata, a popular Central American drink.

When Hackensack University Medical Center sent staff members to teach caregivers how to take care of their patients, one place “didn’t even know what a low-salt diet was,” even though that’s a critical part of keeping heart failure patients from retaining fluids, said Dr. Charles Riccobono, chief quality and safety officer at the New Jersey hospital.

Aurora Health Care, a Milwaukee-based health system, now places its own nurse practitioners in several nursing homes to watch over Aurora’s discharged patients. Aurora says readmission rates of those patients have decreased, in some months by as much as half.

Dr. Eric Coleman, a Denver geriatrician whose ideas on reducing readmissions have been adopted by a number of hospitals and Medicare, said that while some hospital changes are “exciting and new,” others are “relabeling old wine in new bottles.”

“Yesterday we had ‘discharge planning’ and today we have a ‘rapid response transition team,’ and content-wise they’re doing the same thing,” Dr. Coleman said. “But it’s a nice thing to report out to the board of trustees.”

Jordan Rau is a reporter for Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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The Hard Road Back: Prosthetic Arms a Complex Test for Amputees

A Future Reset:
After losing his arm in an I.E.D. explosion in Afghanistan, Cpl. Sebastian Gallegos has adjusted to his prosthetic limb.

SAN ANTONIO — After the explosion, Cpl. Sebastian Gallegos awoke to see the October sun glinting through the water, an image so lovely he thought he was dreaming. Then something caught his eye, yanking him back to grim awareness: an arm, bobbing near the surface, a black hair tie wrapped around its wrist.

The elastic tie was a memento of his wife, a dime-store amulet that he wore on every patrol in Afghanistan. Now, from the depths of his mental fog, he watched it float by like driftwood on a lazy current, attached to an arm that was no longer quite attached to him.

He had been blown up, and was drowning at the bottom of an irrigation ditch.

Two years later, the corporal finds himself tethered to a different kind of limb, a $110,000 robotic device with an electronic motor and sensors able to read signals from his brain. He is in the office of his occupational therapist, lifting and lowering a sponge while monitoring a computer screen as it tracks nerve signals in his shoulder.

Close hand, raise elbow, he says to himself. The mechanical arm rises, but the claw-like hand opens, dropping the sponge. Try again, the therapist instructs. Same result. Again. Tiny gears whir, and his brow wrinkles with the mental effort. The elbow rises, and this time the hand remains closed. He breathes.

Success.

“As a baby, you can hold onto a finger,” the corporal said. “I have to relearn.”

It is no small task. Of the more than 1,570 American service members who have had arms, legs, feet or hands amputated because of injuries in Afghanistan or Iraq, fewer than 280 have lost upper limbs. Their struggles to use prosthetic limbs are in many ways far greater than for their lower-limb brethren.

Among orthopedists, there is a saying: legs may be stronger, but arms and hands are smarter. With myriad bones, joints and ranges of motion, the upper limbs are among the body’s most complex tools. Replicating their actions with robotic arms can be excruciatingly difficult, requiring amputees to understand the distinct muscle contractions involved in movements they once did without thinking.

To bend the elbow, for instance, requires thinking about contracting a biceps, though the muscle no longer exists. But the thought still sends a nerve signal that can tell a prosthetic arm to flex. Every action, from grabbing a cup to turning the pages of a book, requires some such exercise in the brain.

“There are a lot of mental gymnastics with upper limb prostheses,” said Lisa Smurr Walters, an occupational therapist who works with Corporal Gallegos at the Center for the Intrepid at Brooke Army Medical Center in San Antonio.

The complexity of the upper limbs, though, is just part of the problem. While prosthetic leg technology has advanced rapidly in the past decade, prosthetic arms have been slow to catch up. Many amputees still use body-powered hooks. And the most common electronic arms, pioneered by the Soviet Union in the 1950s, have improved with lighter materials and microprocessors but are still difficult to control.

Upper limb amputees must also cope with the critical loss of sensation. Touch — the ability to differentiate baby skin from sandpaper or to calibrate between gripping a hammer and clasping a hand — no longer exists.

For all those reasons, nearly half of upper limb amputees choose not to use prostheses, functioning instead with one good arm. By contrast, almost all lower limb amputees use prosthetic legs.

But Corporal Gallegos, 23, is part of a small vanguard of military amputees who are benefiting from new advances in upper limb technology. Earlier this year, he received a pioneering surgery known as targeted muscle reinnervation that amplifies the tiny nerve signals that control the arm. In effect, the surgery creates additional “sockets” into which electrodes from a prosthetic limb can connect.

More sockets reading stronger signals will make controlling his prosthesis more intuitive, said Dr. Todd Kuiken of the Rehabilitation Institute of Chicago, who developed the procedure. Rather than having to think about contracting both the triceps and biceps just to make a fist, the corporal will be able to simply think, close hand, and the proper nerves should fire automatically.

In the coming years, new technology will allow amputees to feel with their prostheses or use pattern-recognition software to move their devices even more intuitively, Dr. Kuiken said. And a new arm under development by the Pentagon, the DEKA Arm, is far more dexterous than any currently available.

But for Corporal Gallegos, becoming proficient on his prosthesis after reinnervation surgery remains a challenge, likely to take months more of tedious practice. For that reason, only the most motivated amputees — super users, they are called — are allowed to undergo the surgery.

Corporal Gallegos was not always that person.

His father, an Army veteran, did not want him to join the infantry, but it was like him to ignore the advice.

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Egypt’s President Said to Limit Scope of Judicial Decree

Tara Todras-Whitehill for The New York Times

Egyptians at a burned-out school in Cairo on Monday before the funeral of an activist who was injured in a clash and died Sunday.

CAIRO — With public pressure mounting, President Mohamed Morsi appeared to pull back Monday from his attempt to assert an authority beyond the reach of any court. His allies in the Muslim Brotherhood canceled plans for a large demonstration in his support, signaling a chance to calm an escalating battle that has paralyzed a divided nation.

After Mr. Morsi met for hours with the judges of Egypt’s Supreme Judicial Council, his spokesman read an “explanation” on television that appeared to backtrack from a presidential decree placing Mr. Morsi’s official edicts above judicial scrutiny — even while saying the president had not actually changed a word of the statement.

Though details of the talks remained hazy, and it was not clear whether the opposition or the court would accept his position, Mr. Morsi’s gesture was another demonstration that Egyptians would no longer allow their rulers to operate above the law. But there appeared little chance that the gesture alone would be enough to quell the crisis set off by his perceived power grab.

Protesters remained camped in Tahrir Square, and the opposition was moving ahead with plans for a major demonstration on Tuesday.

The presidential spokesman, Yasser Ali, said for the first time that Mr. Morsi had sought only to assert pre-existing powers already approved by the courts under previous precedents, not to free himself from judicial oversight.

He said that the president meant all along to follow an established Egyptian legal doctrine suspending judicial scrutiny of presidential “acts of sovereignty” that work “to protect the main institutions of the state.” The judicial council had said Sunday that it could bless aspects of the decree deemed to qualify under the doctrine.

Mr. Morsi had maintained from the start that his purpose was to empower himself to prevent judges appointed by former President Hosni Mubarak from dissolving the constituent assembly, which is led by his fellow Islamists of the Muslim Brotherhood’s Freedom and Justice Party. The courts have already dissolved the Islamist-led Parliament and an earlier constituent assembly, and the Supreme Constitutional Court was widely expected to rule against this one next week.

But the text of the original decree had exempted all presidential edicts from judicial review until the ratification of a constitution, not just those edicts related to the assembly or justified as “acts of sovereignty.”

Legal experts said that the spokesman’s explanations of the president’s intentions, if put into effect, would amount to a revision of the decree Mr. Morsi issued last Thursday. But lawyers said that the verbal statements alone carried little legal weight.

How the courts would apply the doctrine remained hard to predict. And Mr. Morsi’s opposition indicated it was holding out for far greater concessions, including the breakup of the whole constituent assembly.

Speaking at a news conference while Mr. Morsi was meeting with the judges, the opposition activist and intellectual Abdel Haleem Qandeil called for “a long-term battle,” declaring that withdrawal of Mr. Morsi’s new powers was only the first step toward the opposition’s goal of “the withdrawal of the legitimacy of Morsi’s presence in the presidential palace.” Completely withdrawing the edict would be “a minimum,” he said.

Khaled Ali, a human rights lawyer and former presidential candidate, pointed to the growing crowd of protesters camped out in Tahrir Square for a fourth night. “The one who did the action has to take it back,” Mr. Ali said.

Moataz Abdel Fattah, a political scientist at Cairo University, said Mr. Morsi was saving face during a strategic retreat. “He is trying to simply say, ‘I am not a new pharaoh; I am just trying to stabilize the institutions that we already have,’ ” he said. “But for the liberals, this is now their moment, and for sure they are not going to waste it, because he has given them an excellent opportunity to score.”

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