Scare Amplifies Fears That Clinton’s Work Has Taken Heavy Toll

Pool photo by Brendan Smialowski

Hillary Rodham Clinton with Field Marshal Mohamed Hussein Tantawi in Cairo in July.

WASHINGTON — When Secretary of State Hillary Rodham Clinton fractured her right elbow after slipping in a State Department garage in June 2009, she returned to work in just a few days. Her arm in a sling, she juggled speeches and a trip to India and Thailand with physical therapy, rebuilding a joint held together with wire and pins.

It was vivid evidence of Mrs. Clinton’s indomitable stamina and work ethic — as a first lady, senator, presidential candidate and, for the past four years, the most widely traveled secretary of state in American history.

But after a fall at home in December that caused a concussion, and a subsequent diagnosis of a blood clot in her head, it has taken much longer for Mrs. Clinton to bounce back. She was released from a hospital in New York on Wednesday, accompanied by her daughter, Chelsea, and her husband, former President Bill Clinton. On Thursday, she told colleagues that she hoped to be in the office next week.

Her health scare, though, has reinforced the concerns of friends and colleagues that the years of punishing work and travel have taken a heavy toll. Even among her peers at the highest levels of government, Mrs. Clinton, 65, is renowned for her grueling schedule. Over the past four years, she was on the road for 401 days and spent the equivalent of 87 full days on a plane, according to the State Department’s Web site.

In one 48-hour marathon in 2009 that her aides still talk about, she traveled from talks with Palestinian leaders in Abu Dhabi to a midnight meeting with Prime Minister Benjamin Netanyahu in Jerusalem, then boarded a plane for Morocco, staying up all night to work on other issues, before going straight to a meeting of Arab leaders the next morning.

“So many people who know her have urged me to tell her not to work so hard,” said Melanne S. Verveer, who was Mrs. Clinton’s chief of staff when she was first lady and is now the State Department’s ambassador at large for women’s issues. “Well, that’s not easy to do when you’re Hillary Clinton. She doesn’t spare herself.”

It is not just a matter of duty, Ms. Verveer and others said. Mrs. Clinton genuinely relishes the work, pursuing a brand of personal diplomacy that, she argues, requires her to travel to more places than her predecessors.

While there is no medical evidence that Mrs. Clinton’s clot was caused by her herculean work habits, her cascade of recent health problems, beginning with a stomach virus, has prompted those who know her best to say that she desperately needs a long rest. Her first order of business after leaving the State Department in the coming weeks, they say, should be to take care of herself.

Some even wonder whether this setback will — or should — temper the feverish speculation that she will make another run for the White House in 2016.

“I am amazed at the number of women who come up to me and tell me she must run for president,” said Ellen Chesler, a New York author and a friend of Mrs. Clinton’s. “But perhaps this episode will alter things a bit.”

Given Mrs. Clinton’s enduring status as a role model, Ms. Chesler said women would be watching which path she decides to take, as they plan their own transitions out of the working world.

“Do remember that women of our generation are really the first to have worked through the life cycle in large numbers,” she added. “Many seem to be approaching retirement with dread.”

For now, aides say, Mrs. Clinton’s focus is on wrapping up her work at the State Department. She would like to take part in a town hall-style meeting, thank her staff and sit for some interviews. But first she has to get clearance from her doctors, who are watching her to make sure that the blood thinners they have prescribed for her clot are working.

Speaking to a meeting of a foreign policy advisory board from her home in Chappaqua, N.Y., on Thursday, Mrs. Clinton said she was crossing her fingers and encouraging her doctors to let her return next week. “I’m trying to be a compliant patient,” she said, according to a person who was in the room. “But that does require a certain level of patience, which I’ve had to cultivate over the last three and a half weeks.”

While convalescing, Mrs. Clinton has spoken with President Obama and has held a 30-minute call with Senator John Kerry, Democrat of Massachusetts, whom Mr. Obama nominated as her successor.

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Europe Likely to Be Harder on Google Over Search

PARIS — By some accounts, the United States let Google off the hook when it found that the technology giant had not abused its dominance in the Internet search market.

Yves Logghe/Associated Press

Joaquín Almunia has vowed to restore competition to the Internet search business in Europe.

Few expect the European antitrust watchdog to be as lenient.

The Federal Trade Commission ruled on Thursday that Google had not broken antitrust laws, after a 19-month inquiry into how it operated its search engine. But the European Commission, which is pursuing claims that the company rigs results to favor its own businesses, operates under a different standard.

The agreement with the American authorities, analysts and competition lawyers say, is unlikely to alter the demands of European regulators, led by the competition commissioner, Joaquín Almunia.

“We have taken note of the F.T.C. decision, but we don’t see that it has any direct implications for our investigation, for our discussions with Google, which are ongoing,” said Michael Jennings, a spokesman for the European Commission in Brussels.

Faced with nearly $4 billion in possible penalties and restrictions on its business in Europe, Google submitted proposals in July to remedy the concerns of the European Commission, which covered four areas. In its deal with the F.T.C., Google made concessions in two of those areas but was not required to do so in the rest.

A Google spokesman, Al Verney, declined to comment on the content of the company’s proposals to Mr. Almunia but said the company would “continue to work cooperatively with the European Commission.”

The Google case underscores a basic difference between the approaches to monopoly power in Europe and the United States. American antitrust regulators tend to focus on whether a company’s dominance harms consumers; the European system seeks to keep competitors in the market. Mr. Almunia has vowed to restore competition to the Internet search business in Europe.

“History shows that competition law is applied to monopoly power more stringently in the E.U. than in the U.S.,” said Jacques Lafitte, head of the competition practice at Avisa Partners, a consultancy in Brussels, who brought one of the original complaints against Google. “Whether the E.U. is right or not is a different question.”

Mr. Lafitte has some expertise in the matter. He is the former head of corporate affairs at Microsoft Europe and watched as that company did battle with regulators over its dominant computer operating system. Microsoft won a lenient settlement with the Justice Department in October 2001, he said, only to be slapped with nearly 1.6 billion euros, or $2.1 billion, in fines and penalties from the European Union from 2004 to 2008.

Google learned from Microsoft’s mistakes. It worked with authorities in both the United States and Europe to reach a deal rather than fight a desperate legal action. That approach appears to have paid off: last month, after a meeting with Eric E. Schmidt, Google’s executive chairman, Mr. Almunia said that the sides had “substantially reduced our differences.”

In its deal with the F.T.C., Google agreed to make concessions in two areas that concerned European regulators. In one, it will allow rivals to opt out of allowing Google to “scrape,” or copy, text from their sites. Google will probably offer the same concession to European authorities.

But in a second area of European concern — whether Google deliberately favors its own content in search results — the F.T.C. did not require changes.

Mr. Almunia has also demanded that Google put fewer restrictions on advertising distribution deals, an area his American counterparts did not explore.

The company will make a detailed set of proposed remedies in January. The European Commission will then allow the complainants to review them in a period of what is known as “market testing.” Antitrust lawyers say a final denouement could arrive by spring, depending on how hostile Google’s rivals are to the proposed remedies.

FairSearch, an alliance of Google rivals, accused the F.T.C. of rushing its decision. It said in a statement that closing the F.T.C. investigation “with only voluntary commitments from Google is disappointing and premature.”

The outcome in Europe may also be affected by Google’s dominance there. Google’s share of the United States search market was 67 percent in November, according to comScore, a digital analytics company, while its share in Europe was 83 percent that month.

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Undecided Syrians Could Tip Balance of Rebellion

BEIRUT, Lebanon — At his government office in the Syrian capital, Damascus, the civil servant avoids discussing what Syrians call “the situation.” But he quietly ponders his own private endgame, toying with defecting to the rebels, yet clinging to his post, increasingly sure there are no fighters worth joining.

A multilingual former military officer, he says he is among many friends and colleagues who feel trapped: disenchanted with President Bashar al-Assad, disgusted by the violence engulfing Syria and equally afraid of the government and the rebels, with both sides, as he puts it, ready to sacrifice “the innocents.”

Mr. Assad remains in power in part because two years into the uprising, a critical bloc of Syrians remains on the fence. Among them are business owners who drive the economy, bankers who finance it, and the security officials and government employees who hold the keys to the mundane but crucial business of maintaining an authoritarian state. If they abandoned the government or embraced the rebels en masse, they might change the tide. Instead, their uncertainty contributes to the stalemate.

The Egyptian and Tunisian rebellions that inspired Syria’s initially peaceful uprising reached tipping points within weeks, with far less bloodshed. In those cases, widespread desire for change overwhelmed the fear of the unknown, and toppled governments — or rather, the dictatorial cliques that headed them. But in Syria, each side has bloodied the other while many stay on the sidelines, and a core contingent of supporters feels obligated to stick with the government even as their doubts grow. That is in part because the government’s ruthless crackdown has made protest far more risky than in other uprisings. But it is also because of doubts, among the urban elite and others, about the direction of the revolution and how a rebel-ruled Syria would look.

“Me and my neighbors, we were the first to go down to the street and scream that we want a country, a real country, not a plantation,” said Samar Haddad, who runs a Syrian publishing house. “But this armed revolution, I refuse it as much as I refuse the regime.”

Ms. Haddad, who is in her late 40s and now spends much of her time outside Damascus, said that she and her circle of intellectuals and professionals embrace unarmed Syrian protesters as heroes, but believe that the armed rebellion is creating warlords and cycles of revenge that will be hard to uproot.

The fence sitters include government employees, security forces, intellectuals and wealthy Syrians. Some, including members of Mr. Assad’s minority Alawite sect, say they fear the rule of Islamists, or the calls for vengeance from some factions of the Sunni Muslim-dominated uprising.

Some are former soldiers who say they defected only to be disappointed by rebels who lack discipline or obsess about religious ideology. One young man, Nour, said he gave up on revolution when he tried to join an Islamist brigade, Al Tawhid, but was rejected for wearing skinny jeans.

Others, like the Damascus civil servant, a Sunni, simply fear a post-Assad vacuum and are confused about the safest course for their families and the country.

Fewer and fewer Syrians appear to believe the government can restore order; the fraying of the country has become hard to miss. This has resulted in countless private debates over how to survive — amid growing alarm that without a political settlement or intervention, endless fighting will gut the Syrian state.

For those who support neither Mr. Assad nor his opponents, life has become a fearful wait.

In Damascus, little gets done in offices that tremble with explosions and empty out by dusk. Government salaries are still paid, the civil servant said, but fewer workers show up. Ms. Haddad said her publishing employees still come to work, in what has become an act of defiance to show that life goes on.

Many people express a wish for a political solution — perhaps a transitional government involving moderate government officials — but believe that decisions are being made by armed men on both sides who refuse to compromise.

“Both sides have the same mind,” said Abu Tony, a shopkeeper in central Damascus who favors a compromise and gave only a nickname for safety reasons.

“This is not life,” he said, “to spend half of the day without electricity, without heating oil and without even bread just because the two sides refuse to give up some of their demands.”

Ms. Haddad said she and like-minded friends were trying quietly to build civil society. But she said: “We feel depressed, useless, helpless. We are not the decision makers.”

Even as some Alawites grow frustrated with Mr. Assad — believing he has poisoned their future in Syria — many believe there is no safe place for them on the other side. In part for this reason, there have not been mass defections by senior Alawite military officers.

But even Sunni soldiers under strong pressure to defect sometimes feel that “we can’t offer them much,” said one rebel commander based in the northern province of Idlib.

He said many were in touch with colleagues who defected earlier, who recount months without salaries, and the humiliation of former colonels commanded by junior fighters with swollen egos.

One such disappointed defector is Nour, who said he served in the feared Fourth Division commanded by Mr. Assad’s brother Maher. He said he defected after security forces raped and killed his fiancée and many friends begged him to join the rebels.

But he was let down, first by fighters who drank and took drugs and offered him money for sexual acts; then by Al Tawhid Brigade, whose fighters, he said, taunted him, saying “You want to join us and you’re wearing skinny trousers?” He said he had decided to stay in Turkey and avoid both sides in the conflict.

The Damascus civil servant and would-be defector — who has talked for months about defecting, first to rebels from his hometown and then to a reporter — said he hesitates over many questions about the rebels and their plans: “Are the people aware enough? Can they practice self-control? Can the rebels set up a security zone?”

“Many questions need answers,” he said.

The government, he added, long ago stopped forcing him to attend pro-Assad demonstrations, but rebel supporters call him a traitor for asking questions.

“Why should I join a group where I am obliged to curtsy?”

An employee of The New York Times contributed reporting from Damascus, Syria, and Hania Mourtada from Beirut.

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DealBook: S.E.C. Ends Scrutiny of Former Top Aide to Buffett

The Securities and Exchange Commission has decided not to file insider trading charges against David L. Sokol, a onetime top lieutenant at Berkshire Hathaway, Mr. Sokol’s lawyer said Thursday.

Mr. Sokol came under scrutiny in 2011 after abruptly resigning as chairman of Berkshire’s MidAmerican Energy Holdings, one of the many holdings of the investment conglomerate run by the billionaire Warren E. Buffett. At the time, Berkshire revealed that Mr. Sokol bought shares in Lubrizol, a maker of lubricants that he wanted Mr. Buffett to buy. Mr. Sokol bought the shares about two months before Berkshire announced a $9 billion acquisition of the company. After the deal was announced, the value of his Lubrizol stake rose by $3 million.

But Mr. Sokol’s lawyer, Barry Wm. Levine, said that the S.E.C. informed his client on Thursday that it had completed its inquiry and decided not to pursue a civil enforcement action.

Mr. Levine said he was happy that his client was “exonerated” and that Mr. Sokol never acted improperly in the trades. “He is the paragon of rectitude,” said Mr. Levine, a partner at the law firm Dickstein Shapiro in Washington.

John Nester, a spokesman for the S.E.C., declined to comment on Thursday. The agency typically does not comment when it decides not to pursue action in such cases. The news was first reported online by The Wall Street Journal.

Mr. Sokol’s resignation in 2011 was a rare black eye for Berkshire. A star manager, Mr. Sokol had run several Berkshire subsidiaries, including MidAmerican Energy and NetJets, which sells fractional ownerships of private jets. He was long considered to be a leading candidate to succeed Mr. Buffett, 82.

Mr. Sokol, now 56, had also become a crucial player in the conglomerate’s frequent deal-making, earning the nickname “Mr. Fix-it.” He served as a point man for Mr. Buffett on a number of potential transactions, particularly during the financial crisis.

His sudden resignation caught Berkshire by surprise. Mr. Buffett said he did not ask for Mr. Sokol’s resignation, suggesting at the time that it was a personal decision by Mr. Sokol.

Mr. Buffett initially defended his protégé’s trading. “Neither Dave nor I feel his Lubrizol purchases were in any way unlawful,” Mr. Buffett said at the time.

But additional information surfaced after the Berkshire board investigated Mr. Sokol’s trading record. Berkshire directors ultimately accused Mr. Sokol of misleading the company about his personal stake in Lubrizol.

Mr. Sokol bought $10 million worth of stock in Lubrizol shortly before bringing the company to Mr. Buffett’s attention, according to the board. While Mr. Sokol made a “passing remark” to Mr. Buffett about his trading, the board said that Mr. Sokol did not tell Mr. Buffett that he had bought his stake in Lubrizol after Citigroup bankers had pitched the company as a potential takeover target. He also bought some of the shares, according to the Berkshire directors, after learning that Lubrizol might entertain a takeover offer.

“His misleadingly incomplete disclosures to Berkshire Hathaway senior management concerning those purchases violated the duty of candor he owed the company,” the board’s report in 2011 says. It adds that Mr. Sokol may have failed his fiduciary duty under the law of Delaware, where Berkshire is incorporated.

At the time, Mr. Levine said that Mr. Sokol was considering a personal investment in Lubrizol since summer 2010, before meeting with bankers to discuss the company as a potential takeover target.

Still, Mr. Buffett said the trades violated company trading policy and called Mr. Sokol’s actions “inexplicable and inexcusable.”

He also provided testimony to S.E.C. investigators. Meanwhile, Berkshire continued to pay Mr. Sokol’s legal bills. Last spring, Mr. Buffett claimed those bills reached nearly $200,000 a month.

Mr. Buffett could not be immediately reached for comment on Thursday night.

But later in 2012, S.E.C. lawyers decided that there was insufficient evidence to mount a case against Mr. Sokol. The evidence was circumstantial, S.E.C. officials concluded, and it was unclear whether Mr. Sokol had a true window into the Lubrizol deal-making process. He also had no indication at the time of his stock trades that Mr. Buffett would be interested in acquiring the company.

Since resigning from Berkshire, Mr. Sokol has been managing his own portfolio, Mr. Levine said.

Pradnya Joshi contributed reporting.

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This post has been revised to reflect the following correction:

Correction: January 4, 2013

A summary with an earlier version of this article misspelled the surname of the billionaire investor. He is Warren E. Buffett, not Bufett.

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Scant Proof Is Found to Back Up Claims by Energy Drinks

Energy drinks are the fastest-growing part of the beverage industry, with sales in the United States reaching more than $10 billion in 2012 — more than Americans spent on iced tea or sports beverages like Gatorade.

Their rising popularity represents a generational shift in what people drink, and reflects a successful campaign to convince consumers, particularly teenagers, that the drinks provide a mental and physical edge.

The drinks are now under scrutiny by the Food and Drug Administration after reports of deaths and serious injuries that may be linked to their high caffeine levels. But however that review ends, one thing is clear, interviews with researchers and a review of scientific studies show: the energy drink industry is based on a brew of ingredients that, apart from caffeine, have little, if any benefit for consumers.

“If you had a cup of coffee you are going to affect metabolism in the same way,” said Dr. Robert W. Pettitt, an associate professor at Minnesota State University in Mankato, who has studied the drinks.

Energy drink companies have promoted their products not as caffeine-fueled concoctions but as specially engineered blends that provide something more. For example, producers claim that “Red Bull gives you wings,” that Rockstar Energy is “scientifically formulated” and Monster Energy is a “killer energy brew.” Representative Edward J. Markey of Massachusetts, a Democrat, has asked the government to investigate the industry’s marketing claims.

Promoting a message beyond caffeine has enabled the beverage makers to charge premium prices. A 16-ounce energy drink that sells for $2.99 a can contains about the same amount of caffeine as a tablet of NoDoz that costs 30 cents. Even Starbucks coffee is cheap by comparison; a 12-ounce cup that costs $1.85 has even more caffeine.

As with earlier elixirs, a dearth of evidence underlies such claims. Only a few human studies of energy drinks or the ingredients in them have been performed and they point to a similar conclusion, researchers say — that the beverages are mainly about caffeine.

Caffeine is called the world’s most widely used drug. A stimulant, it increases alertness, awareness and, if taken at the right time, improves athletic performance, studies show. Energy drink users feel its kick faster because the beverages are typically swallowed quickly or are sold as concentrates.

“These are caffeine delivery systems,” said Dr. Roland Griffiths, a researcher at Johns Hopkins University who has studied energy drinks. “They don’t want to say this is equivalent to a NoDoz because that is not a very sexy sales message.”

A scientist at the University of Wisconsin became puzzled as he researched an ingredient used in energy drinks like Red Bull, 5-Hour Energy and Monster Energy. The researcher, Dr. Craig A. Goodman, could not find any trials in humans of the additive, a substance with the tongue-twisting name of glucuronolactone that is related to glucose, a sugar. But Dr. Goodman, who had studied other energy drink ingredients, eventually found two 40-year-old studies from Japan that had examined it.

In the experiments, scientists injected large doses of the substance into laboratory rats. Afterward, the rats swam better. “I have no idea what it does in energy drinks,” Dr. Goodman said.

Energy drink manufacturers say it is their proprietary formulas, rather than specific ingredients, that provide users with physical and mental benefits. But that has not prevented them from implying otherwise.

Consider the case of taurine, an additive used in most energy products.

On its Web site, the producer of Red Bull, for example, states that “more than 2,500 reports have been published about taurine and its physiological effects,” including acting as a “detoxifying agent.” In addition, that company, Red Bull of Austria, points to a 2009 safety study by a European regulatory group that gave it a clean bill of health.

But Red Bull’s Web site does not mention reports by that same group, the European Food Safety Authority, which concluded that claims about the benefits in energy drinks lacked scientific support. Based on those findings, the European Commission has refused to approve claims that taurine helps maintain mental function and heart health and reduces muscle fatigue.

Taurine, an amino acidlike substance that got its name because it was first found in the bile of bulls, does play a role in bodily functions, and recent research suggests it might help prevent heart attacks in women with high cholesterol. However, most people get more than adequate amounts from foods like meat, experts said. And researchers added that those with heart problems who may need supplements would find far better sources than energy drinks.

Hiroko Tabuchi contributed reporting from Tokyo and Poypiti Amatatham from Bangkok.

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Gadgetwise Blog: App Smart Extra: Keeping Fitness Resolutions

This week App Smart was full of apps that can help you, one way or another, to stick to any New Year’s resolutions you’ve made.

Making a resolution to keep healthy is pretty common, and like me you may have resolved to improve your fitness by going for a regular jog. The iFit Running app ($2 on iOS) is great for this because it can track your runs using GPS, help you keep note of your timings and even measure your daily calorie intake. To keep you motivated when you’re running, it has voice prompts, or you can turn on a metronome to help keep your pace steady or play music.

Stopping smoking is another common health resolution, and the free and highly popular Android app Quit Now! (free on Google Play) could be ideal for helping you kick the habit. This app’s main trick for motivating you is a list of statistics about how long it’s been since you smoked your last cigarette, and roughly how much time and money you’ve saved — the dollars will rack up very quickly! There’s also a social networking system so you can chat with other people battling the habit.

For a really simple iOS app to help you commit to keeping your resolutions, try Commit ($3 on iTunes). It’s very cleanly designed. You simply enter your goal, and when you’ve achieved it each day you can tap on the giant tick mark button. Several goals can be entered, each accessed by a simple swipe gesture, and the app displays a progress bar to show you how many days in a row you’ve clicked on the tick for each goal. There’s not much else to this app, but the simplicity may keep you using it. Commit really only takes a second to fire up and click on the button.

Learning a language is another popular New Year’s resolution, and newly updated app TripLingo (free on iOS) could help you with the task — and also when you’re vacationing in another country. It’s not designed to be an exhaustive dictionary, but it does have an extensive offline dictionary system and it has several tricks for teaching you useful phrases, including slang words.

Good luck keeping your resolutions, folks!

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News Analysis: Debt Deal Fails to Allay Fears on U.S. Global Power

WASHINGTON — Two years ago the departing chairman of the Joint Chiefs of Staff, Adm. Mike Mullen, declared that “the most significant threat to our national security is our debt.” After a decade in which the nation had chased Al Qaeda and invaded Iraq, Admiral Mullen was saying, in essence, that the biggest enemy was us.

Paula Bronstein/Getty Images

Some analysts worry that the United States will not maintain influence in places like Myanmar.

Now that Congress and President Obama have slipped past the latest budget deadline with a bill that does little to address the country’s long-term debt issues — and by some measures might worsen them — the worries of the national security establishment have been reignited. Most pointedly, military and diplomatic experts wonder whether the United States is at risk of squandering its global influence.

“There’s a sense that we’ve been playing roulette with our position, and this deal does nothing to stop that,” Richard N. Haass, the president of Council on Foreign Relations, said in an interview. His coming book, “Foreign Policy Begins at Home,” is part of a wave of recent literature arguing that America’s reduced global ambitions are linked to its status as a debtor nation.

Vali Nasr, who will soon publish “The Dispensable Nation,” argues that the debt, among other economic woes, has allowed Mr. Obama and other Democrats to justify a retreat from global engagement. “It’s made it far easier to say ‘We can’t do more,’ ” said Mr. Nasr, the dean of the School of Advanced International Studies at Johns Hopkins University. “And without addressing the debt issues, it will be easier to make that argument for years to come.”

A departing senior diplomat at the State Department who requested anonymity, ruminating on the outcome of the confrontation on the fiscal crisis, said that the failure to attack the long-term debt issues would become another reason “to turn our backs on the Middle East and trim our sails on the new focus on Asia.”

That is the theme that the Chinese — who have an interest in portraying the United States as a declining power unable to manage its economy — are already promoting. “The politicians have chosen to kick the can down the road,” the state-run Xinhua news agency said in a commentary on Wednesday. “The can will never disappear,” it continued, warning that the United States was falling “into an abyss you can never come out of.”

Most evidence suggests that the country’s debt is not an immediate crisis. The deficit is expected to shrink somewhat in coming years, and even after the United States lost its AAA bond rating, foreigners have remained willing to lend the country money at very low interest rates. That is a sign of confidence in the American economy and a recognition that Europe and Asia have problems of their own.

But the aging of the population and the growth of health costs will most likely cause the deficit to grow rapidly in coming decades, meaning that the most difficult choices about taxes and spending are still ahead. Absent decisions on those issues, the government will have fewer resources and be more dependent on foreign lenders — increasingly the Chinese.

“Partly it is about resources,” Mr. Haass said, referring to the national security implications of the deficit. “But it is also about reducing your vulnerability to the machinations of currency markets and potentially hostile central bankers” who choose whether to buy American debt.

“When we appear to be dysfunctional, as we have in recent times, it makes it hard to be the model for the democratic, capitalistic model we say we want to be in the world,” he added.

History suggests that the relationship between debt and American power is a complex one, subject to differing interpretations by both economists and historians. The federal debt exceeded 100 percent of the gross domestic product at the end of World War II, but the postwar period nonetheless marked the beginning of America’s superpower status. The debt fell fairly steadily during the cold war, and it was cut to about a third of gross domestic product by the end of the Nixon administration — even as the country retreated into a post-Vietnam War funk.

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Your Money: Piecing Together a Tax Plan’s Effects

It is tempting for people who earn less than $400,000 to think that they got off easy this week under the tax deal to end the fiscal impasse, given that only those with incomes above that level will be in a higher income tax bracket in 2013.

But the legislation that both houses of Congress have now approved could increase taxes on people with incomes that are not quite that high as well. That’s because the bill includes language that begins to do what both President Obama and Mitt Romney proposed at various points in the past: Limit certain tax breaks available to people who are affluent.

The new rules target two tax breaks: personal exemptions and many popular deductions like those for state and local taxes, mortgage interest and charitable contributions. For both breaks, single people with at least $250,000 in adjusted gross income and married people filing jointly with at least $300,000 in income are vulnerable. A hypothetical Texas couple could end up paying about $2,500 more in taxes, for instance.

The mechanics of how the new limits will work are now clear, though it takes a fair bit of explaining to lay them out in plain English. What we don’t know yet is how many people will end up paying more in 2013 than they did in 2012.

The uncertainty is tied to the fact that many of the targets of the legislation often end up ensnared by the alternative minimum tax. The A.M.T., and its high tax bill, may continue to catch most of them.

But let’s start with the basics. Most of the discussion here begins with that adjusted gross income figure. That’s the number you get when you subtract items from your salary or take-home pay that are often referred to as above-the-line deductions.

For the income range we’re talking about, these deductions tend to include things like health savings account contributions and alimony. People who work for themselves also get deductions for health insurance premiums, certain retirement contributions and self-employment taxes that an employer would otherwise pay.

Mark Luscombe, principal analyst with CCH, a tax information provider, points out just how confusing the use of adjustable gross income is, given that the new tax limits, the new tax bracket and the new Medicare tax are all based on different definitions of income.

Under normal circumstances, a personal exemption, for a specific dollar amount, is available for each member of your household. You then add all of the exemptions and subtract the total from your adjusted gross income, which has the effect of lowering your taxable income. CCH predicts that the personal exemption amount for 2013 will be $3,900 per person.

The new law requires taxpayers in the targeted income range to reduce the amount of their exemptions by 2 percent for every $2,500 by which their income exceeds the $250,000 or $300,000 limit. So a married, childless couple with $400,000 in adjusted gross income and $7,800 in potential exemptions could lose $6,240 of that $7,800.

The math for the limit on deductions is different. There, the rules call for you to add up the applicable deductions. Let’s say that equals $50,000. Then, you subtract from that 3 percent of the amount by which your adjusted gross income exceeds those $250,000 or $300,000 thresholds.

So if you’re a married couple with $400,000 in income, you’re $100,000 over the threshold. Three percent of that is $3,000. So you’d subtract that from $50,000. The rule, which existed for years but had been phased out more recently, is known as the Pease limitation, for Representative Donald J. Pease, the Ohio newspaper editor-turned-legislator who got it passed. As before, you can’t lose more than 80 percent of your deductions, no matter how high your income gets.

If you’re trying to figure out whether and how this may affect you, well, join the club. So much depends on your income, your state and your various deductions. All of that will affect whether the A.M.T. hits you as well.

For people who are already in the A.M.T. but will not end up with the $400,000 (for individuals) or $450,000 (for married couples filing jointly) in income necessary to be in the new 39.6 percent tax bracket in 2013, the new exemption and deduction rules may not hurt you. “I don’t think there’s enough there that you would no longer be in the A.M.T.,” said Jude Coard, a tax partner at Berdon L.L.P., of people with income in the $300,000 to $400,000 range.

Much will depend on your own situation. CCH ran two hypothetical cases for me, which you can see in the accompanying graphic. The first examined a family of four in New York with $400,000 in adjusted gross income and $79,000 in total itemized deductions. The household pays the A.M.T. in both 2012 and under the new tax rules in 2013. They pay just $790 more in 2013, but that includes $1,350 in new Medicare taxes. (The total does not include the Social Security payroll tax that has been restored to its prerecession level.)

A family in Texas, however, might have the same income but lower property taxes and no income tax and thus lower deductions for its federal tax return. Their deductions are just $43,700, but they end up being hurt more by the new rules. They would have no A.M.T. liability in 2013 and would end up paying $3,852 more, or about $2,500 if you don’t count the $1,350 from the new Medicare tax.

This is a lot to digest, so much so that even the experts at the Tax Policy Center have not yet finished updating their online calculator. Once they do, if you have the stomach to gather (or try to predict) all of the data, you can take your shot at projecting what these new rules may cost you.

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The New Old Age Blog: On the Way to Hospice, Surprising Hurdles

I’ve often wondered why more families don’t call hospice when a loved one has a terminal disease — and why people who do call wait so long, often until death is just days away.

Even though more than 40 percent of American deaths now involve hospice care, many families still are trying to shoulder the burden on their own rather than turning to a proven source of help and knowledge. I’ve surmised that the reason is families’ or patients’ unwillingness to acknowledge the prospect of death, or physicians’ inability to say the h-word and refer dying patients to hospice care.

But maybe there’s another reason. A study in the journal Health Affairs recently pointed out that hospices themselves may be turning away patients because of certain restrictive enrollment policies. It’s possible, too, that physicians who know of these policies aren’t referring patients whom the doctors fear wouldn’t qualify.

Surprisingly, this randomized national survey of almost 600 hospice programs represents the first broad inquiry into enrollment practices, though it’s been nearly 30 years since hospice became a Medicare benefit.

Nearly 80 percent of hospice programs, the study found, reported having at least one policy that could restrict access. “It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a geriatrics and palliative care researcher at the Mount Sinai School of Medicine.

What kind of barriers are we talking about? More than 60 percent of hospices won’t accept a patient on chemotherapy, and more than half won’t take someone relying on intravenous nutrition. Many won’t enroll patients receiving palliative radiation or blood transfusions; a few say no to tube feeding.

This made more sense a couple of decades ago, when Medicare developed the regulations requiring patients to forgo curative treatments when they entered hospice. Hospice patients must have a terminal disease, likely to cause death within six months, so such treatments were presumed futile.

But medicine evolves. Now, Dr. Aldridge Carlson pointed out, the distinction between curative and palliative treatments has grown blurry. “It’s increasingly an artificial dichotomy,” she said. “That’s not the reality for most patients today with end-stage disease.”

Chemotherapy, for instance, is often used to shrink tumors that cause pain; radiation can prevent nausea and vomiting for patients with bowel obstructions. Though neither will cure a terminal cancer, as palliative treatments they can improve quality of life. Blood transfusions can help anemic cancer patients feel better, too, at least for a while.

Why, then, would hospices not accept dying people using these treatments? First, these are expensive to provide. The national average Medicare reimbursement for hospice care is just $140 a day, the study notes, and it’s not adjusted to reflect the cost of more complicated regimens. Besides, hospices worry about running afoul of Medicare regulations and being denied even that inadequate reimbursement.

This probably explains why the researchers found that smaller hospices were more likely than large ones to say no to patients receiving such treatments. “If you’re a small hospice caring for someone with many medical issues and the reimbursement doesn’t even cover the care – and then Medicare comes to take it back – that’s a big hit,” Dr. Aldridge Carlson said. Larger organizations with more patients and bigger budgets can better absorb the costs.

One bright note, though, is that almost 30 percent of the hospices studied offer some kind of open access enrollment without insisting on those prohibitions. Much more common in nonprofit hospices (a pity, because the real growth is in for-profit ones), open access usually means enrolling people who don’t yet meet the Medicare criteria, then converting them to Medicare patients as they become eligible.

At Gilchrist Hospice Care in Baltimore, for instance, patients still using chemotherapy, radiation, transfusions and several other treatments can enter what it calls “expanded care,” sometimes also known as “concurrent care.” (At Gilchrist, however, such patients still must meet the six-month hospice eligibility requirement.)

“If you say, ‘You can’t get blood transfusions any more,’ people say, ‘Why would I go with your program?’” said Regina Bodnar, Gilchrist’s clinical director. The hospice’s concurrent program “is not so either/or.”

People who enter hospice care with palliative treatments usually decide to forgo them anyway when they become less effective or more burdensome, Ms. Bodnar said, but “this allows people to make the transition over time.” As the largest hospice program in Maryland, a nonprofit with generous donors, Gilchrist can afford this more flexible, but expensive, approach.

Could it be the future of hospice? That would require Medicare to make some changes in eligibility and reimbursement practices — a shift that might bolster Medicare’s solvency, too.

“Hospice saves money because it keeps people out of the hospital,” Dr. Aldridge Carlson said. Even more expensive outpatient treatments, like palliative radiation, are less costly than days spent in intensive care. Adjusting policies to allow more patients into hospice might bring costs down.

But as important, it could make the call to hospice a slightly less terrifying prospect and provide more families with the help they need at the end of life. “We need to take down the barriers to hospice care,” Ms. Bodnar said, “and this is one way to do it.”

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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: On the Way to Hospice, Surprising Hurdles

I’ve often wondered why more families don’t call hospice when a loved one has a terminal disease — and why people who do call wait so long, often until death is just days away.

Even though more than 40 percent of American deaths now involve hospice care, many families still are trying to shoulder the burden on their own rather than turning to a proven source of help and knowledge. I’ve surmised that the reason is families’ or patients’ unwillingness to acknowledge the prospect of death, or physicians’ inability to say the h-word and refer dying patients to hospice care.

But maybe there’s another reason. A study in the journal Health Affairs recently pointed out that hospices themselves may be turning away patients because of certain restrictive enrollment policies. It’s possible, too, that physicians who know of these policies aren’t referring patients whom the doctors fear wouldn’t qualify.

Surprisingly, this randomized national survey of almost 600 hospice programs represents the first broad inquiry into enrollment practices, though it’s been nearly 30 years since hospice became a Medicare benefit.

Nearly 80 percent of hospice programs, the study found, reported having at least one policy that could restrict access. “It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a geriatrics and palliative care researcher at the Mount Sinai School of Medicine.

What kind of barriers are we talking about? More than 60 percent of hospices won’t accept a patient on chemotherapy, and more than half won’t take someone relying on intravenous nutrition. Many won’t enroll patients receiving palliative radiation or blood transfusions; a few say no to tube feeding.

This made more sense a couple of decades ago, when Medicare developed the regulations requiring patients to forgo curative treatments when they entered hospice. Hospice patients must have a terminal disease, likely to cause death within six months, so such treatments were presumed futile.

But medicine evolves. Now, Dr. Aldridge Carlson pointed out, the distinction between curative and palliative treatments has grown blurry. “It’s increasingly an artificial dichotomy,” she said. “That’s not the reality for most patients today with end-stage disease.”

Chemotherapy, for instance, is often used to shrink tumors that cause pain; radiation can prevent nausea and vomiting for patients with bowel obstructions. Though neither will cure a terminal cancer, as palliative treatments they can improve quality of life. Blood transfusions can help anemic cancer patients feel better, too, at least for a while.

Why, then, would hospices not accept dying people using these treatments? First, these are expensive to provide. The national average Medicare reimbursement for hospice care is just $140 a day, the study notes, and it’s not adjusted to reflect the cost of more complicated regimens. Besides, hospices worry about running afoul of Medicare regulations and being denied even that inadequate reimbursement.

This probably explains why the researchers found that smaller hospices were more likely than large ones to say no to patients receiving such treatments. “If you’re a small hospice caring for someone with many medical issues and the reimbursement doesn’t even cover the care – and then Medicare comes to take it back – that’s a big hit,” Dr. Aldridge Carlson said. Larger organizations with more patients and bigger budgets can better absorb the costs.

One bright note, though, is that almost 30 percent of the hospices studied offer some kind of open access enrollment without insisting on those prohibitions. Much more common in nonprofit hospices (a pity, because the real growth is in for-profit ones), open access usually means enrolling people who don’t yet meet the Medicare criteria, then converting them to Medicare patients as they become eligible.

At Gilchrist Hospice Care in Baltimore, for instance, patients still using chemotherapy, radiation, transfusions and several other treatments can enter what it calls “expanded care,” sometimes also known as “concurrent care.” (At Gilchrist, however, such patients still must meet the six-month hospice eligibility requirement.)

“If you say, ‘You can’t get blood transfusions any more,’ people say, ‘Why would I go with your program?’” said Regina Bodnar, Gilchrist’s clinical director. The hospice’s concurrent program “is not so either/or.”

People who enter hospice care with palliative treatments usually decide to forgo them anyway when they become less effective or more burdensome, Ms. Bodnar said, but “this allows people to make the transition over time.” As the largest hospice program in Maryland, a nonprofit with generous donors, Gilchrist can afford this more flexible, but expensive, approach.

Could it be the future of hospice? That would require Medicare to make some changes in eligibility and reimbursement practices — a shift that might bolster Medicare’s solvency, too.

“Hospice saves money because it keeps people out of the hospital,” Dr. Aldridge Carlson said. Even more expensive outpatient treatments, like palliative radiation, are less costly than days spent in intensive care. Adjusting policies to allow more patients into hospice might bring costs down.

But as important, it could make the call to hospice a slightly less terrifying prospect and provide more families with the help they need at the end of life. “We need to take down the barriers to hospice care,” Ms. Bodnar said, “and this is one way to do it.”

---

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

Read More..