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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The Saturday Profile: After Years in Solitary, an Austere Life as Uruguay’s President

Matilde Campodonico for The New York Times

José Mujica preparing a mate, the herbal drink offered in a hollowed calabash gourd, in his kitchen.

In a deliberate statement to this cattle-exporting nation of 3.3 million people, Mr. Mujica, 77, shunned the opulent Suárez y Reyes presidential mansion, with its staff of 42, remaining instead in the home where he and his wife have lived for years, on a plot of land where they grow chrysanthemums for sale in local markets.

Visitors reach Mr. Mujica’s austere dwelling after driving down O’Higgins Road, past groves of lemon trees. His net worth upon taking office in 2010 amounted to about $1,800 — the value of the 1987 Volkswagen Beetle parked in his garage. He never wears a tie and donates about 90 percent of his salary, largely to a program for expanding housing for the poor.

His current brand of low-key radicalism — a marked shift from his days wielding weapons in an effort to overthrow the government — exemplifies Uruguay’s emergence as arguably Latin America’s most socially liberal country.

Under Mr. Mujica, who took office in 2010, Uruguay has drawn attention for seeking to legalize marijuana and same-sex marriage, while also enacting one of the region’s most sweeping abortion rights laws and sharply boosting the use of renewable energy sources like wind and biomass.

As illness drives President Hugo Chávez of Venezuela from the political stage, suddenly leaving the continent without the larger-than-life figure who has held such sway on the left, Mr. Mujica’s practiced asceticism is a study in contrasts. For democracy to function properly, he argues, elected leaders should be taken down a notch.

“We have done everything possible to make the presidency less venerated,” Mr. Mujica said in an interview one recent morning, after preparing a serving in his kitchen of mate, the herbal drink offered in a hollowed calabash gourd and commonly shared in dozens of sips through the same metal straw.

Passing around the gourd, he acknowledged that his laid-back presidential lifestyle might seem unusual. Still, he said it amounted to a conscious choice to forgo the trappings of power and wealth. Quoting the Roman court-philosopher Seneca, Mr. Mujica said, “It is not the man who has too little, but the man who craves more, who is poor.”

THE leader at the helm of Uruguay’s changes, known to his many detractors and supporters alike as Pepe, is someone few thought could ever rise to such a position. Before Mr. Mujica became a gardener of chrysanthemums, he was a leader of the Tupamaros, the urban guerrilla group that drew inspiration from the Cuban revolution, carrying out armed bank robberies and kidnappings on Montevideo’s streets.

In their war against the Uruguayan state, the Tupamaros gained notoriety through violence. The filmmaker Constantin Costa-Gavras drew inspiration for his 1972 movie, “State of Siege,” from their abduction and execution in 1970 of Daniel Mitrione, an American adviser to Uruguay’s security forces. Mr. Mujica has said that the group “tried by all means to avoid killings,” but he has also euphemistically acknowledged its “military deviations.”

A brutal counterinsurgency subdued the Tupamaros, and the police captured Mr. Mujica in 1972. He spent 14 years in prison, including more than a decade in solitary confinement, often in a hole in the ground. During that time, he would go more than a year without bathing, and his companions, he said, were a tiny frog and rats with whom he shared crumbs of bread.

Some of the other Tupamaros who were placed for years in solitary confinement failed to grasp the benefits of befriending rodents. One of them, Henry Engler, a medical student, underwent a severe mental breakdown before his release in 1985.

Mr. Mujica rarely speaks about his time in prison. Seated at a table in his garden, sipping his mate, he said it gave him time to reflect. “I learned that one can always start again,” he said.

He chose to start again by entering politics. Elected as a legislator, he shocked the parking attendants at Parliament by arriving on a Vespa. After the rise to power in 2004 of the Broad Front, a coalition of leftist parties and more centrist social democrats, he was named minister of Livestock, Agriculture and Fisheries.

Before Mr. Mujica won the 2009 election by a wide margin, his opponent, Luis Alberto Lacalle, disparaged his small house here as a “cave.” After that, Mr. Mujica also upset some in Uruguay’s political establishment by selling off a presidential residence in a seaside resort city, calling the property “useless.”

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Google’s Lawyers Work Behind the Scenes to Carry the Day

SAN FRANCISCO — For 19 months, Google pressed its case with antitrust regulators investigating the company. Working relentlessly behind the scenes, executives made frequent flights to Washington, laying out their legal arguments and shrewdly applying lessons learned from Microsoft’s bruising antitrust battle in the 1990s.

After regulators had pored over nine million documents, listened to complaints from disgruntled competitors and took sworn testimony from Google executives, the government concluded that the law was on Google’s side. At the end of the day, they said, consumers had been largely unharmed.

That is why one of the biggest antitrust investigations of an American company in years ended with a slap on the wrist Thursday, when the Federal Trade Commission closed its investigation of Google’s search practices without bringing a complaint. Google voluntarily made two minor concessions.

“The way they managed to escape it is through a barrage of not only political officials but also academics aligned against doing very much in this particular case,” said Herbert Hovenkamp, a professor of antitrust law at the University of Iowa who has worked as a paid adviser to Google in the past. “The first sign of a bad antitrust case is lack of consumer harm, and there just was not any consumer harm emerging in this very long investigation.”

The F.T.C. had put serious effort into its investigation of Google. Jon Leibowitz, the agency’s chairman, has long advocated for the commission to flex its muscle as an enforcer of antitrust laws, and the commission had hired high-powered consultants, including Beth A. Wilkinson, an experienced litigator, and Richard J. Gilbert, a well-known economist.

Still, Mr. Leibowitz said during a news conference announcing the result of the inquiry, the evidence showed that Google “doesn’t violate American antitrust laws.”

“The conclusion is clear: Google’s services are good for users and good for competition,” David Drummond, Google’s chief legal officer, wrote in a company blog post.

The main thrust of the investigation was into how Google’s search results had changed since it expanded into new search verticals, like local business listings and comparison shopping. A search for pizza or jeans, for instance, now shows results with photos and maps from Google’s own local business service and its shopping product more prominently than links to other Web sites, which has enraged competing sites.

But while the F.T.C. said that Google’s actions might have hurt individual competitors, over all it found that the search engine helped consumers, as evidenced by Google users’ clicking on the products that Google highlighted and competing search engines’ adopting similar approaches.

Google outlined these kinds of arguments to regulators in many meetings over the last two years, as it has intensified its courtship of Washington, with Google executives at the highest levels, as well as lawyers, lobbyists and engineers appearing in the capital.

One of the arguments they made, according to people briefed on the discussions, was that technology is such a fast-moving industry that regulatory burdens would hinder its evolution. Google makes about 500 changes to its search algorithm each year, so results look different now than they did even six months ago.

The definition of competition in the tech industry is also different and constantly changing, Google argued.

For instance, just recently Amazon and Apple, which used to be in different businesses than Google, have become its competitors. Google’s share of the search market has stayed at about two-thirds even though competing search engines are “just a click away,” as the company repeatedly argued. That would become the company’s mantra to demonstrate that it was not abusing its market power.

Claire Cain Miller reported from San Francisco, and Nick Wingfield from Seattle.

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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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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.

Read More..

Google’s Lawyers Work Behind the Scenes to Carry the Day

SAN FRANCISCO — For 19 months, Google pressed its case with antitrust regulators investigating the company. Working relentlessly behind the scenes, executives made frequent flights to Washington, laying out their legal arguments and shrewdly applying lessons learned from Microsoft’s bruising antitrust battle in the 1990s.

After regulators had pored over nine million documents, listened to complaints from disgruntled competitors and took sworn testimony from Google executives, the government concluded that the law was on Google’s side. At the end of the day, they said, consumers had been largely unharmed.

That is why one of the biggest antitrust investigations of an American company in years ended with a slap on the wrist Thursday, when the Federal Trade Commission closed its investigation of Google’s search practices without bringing a complaint. Google voluntarily made two minor concessions.

“The way they managed to escape it is through a barrage of not only political officials but also academics aligned against doing very much in this particular case,” said Herbert Hovenkamp, a professor of antitrust law at the University of Iowa who has worked as a paid adviser to Google in the past. “The first sign of a bad antitrust case is lack of consumer harm, and there just was not any consumer harm emerging in this very long investigation.”

The F.T.C. had put serious effort into its investigation of Google. Jon Leibowitz, the agency’s chairman, has long advocated for the commission to flex its muscle as an enforcer of antitrust laws, and the commission had hired high-powered consultants, including Beth A. Wilkinson, an experienced litigator, and Richard J. Gilbert, a well-known economist.

Still, Mr. Leibowitz said during a news conference announcing the result of the inquiry, the evidence showed that Google “doesn’t violate American antitrust laws.”

“The conclusion is clear: Google’s services are good for users and good for competition,” David Drummond, Google’s chief legal officer, wrote in a company blog post.

The main thrust of the investigation was into how Google’s search results had changed since it expanded into new search verticals, like local business listings and comparison shopping. A search for pizza or jeans, for instance, now shows results with photos and maps from Google’s own local business service and its shopping product more prominently than links to other Web sites, which has enraged competing sites.

But while the F.T.C. said that Google’s actions might have hurt individual competitors, over all it found that the search engine helped consumers, as evidenced by Google users’ clicking on the products that Google highlighted and competing search engines’ adopting similar approaches.

Google outlined these kinds of arguments to regulators in many meetings over the last two years, as it has intensified its courtship of Washington, with Google executives at the highest levels, as well as lawyers, lobbyists and engineers appearing in the capital.

One of the arguments they made, according to people briefed on the discussions, was that technology is such a fast-moving industry that regulatory burdens would hinder its evolution. Google makes about 500 changes to its search algorithm each year, so results look different now than they did even six months ago.

The definition of competition in the tech industry is also different and constantly changing, Google argued.

For instance, just recently Amazon and Apple, which used to be in different businesses than Google, have become its competitors. Google’s share of the search market has stayed at about two-thirds even though competing search engines are “just a click away,” as the company repeatedly argued. That would become the company’s mantra to demonstrate that it was not abusing its market power.

Claire Cain Miller reported from San Francisco, and Nick Wingfield from Seattle.

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Pakistani Girl Shot by Taliban Leaves British Hospital

Dylan Martinez/Reuters

Malala Yousafzai, 15, was discharged from Queen Elizabeth Hospital in Birmingham on Thursday but is due to be readmitted in late January or early February for reconstructive surgery to her skull, doctors said.

LONDON (Reuters) — A Pakistani girl shot in the head by the Taliban for advocating girls’ education has been discharged from a British hospital after doctors said she was well enough to spend time recovering with her family.

Fifteen-year-old Malala Yousafzai, who was shot by the Taliban in October and brought to Britain for treatment, was discharged on Thursday but is due to be re-admitted in late January or early February for reconstructive surgery to her skull, doctors said.

The shooting of Yousafzai, in the head at point blank range as she left school in the Swat valley, drew widespread international condemnation.

She has become a an internationally recognized symbol of resistance to the Taliban’s efforts to deny women education and other rights, and more than 250,000 people have signed online petitions calling for her to be nominated for a Nobel Peace Prize for her activism.

Doctors at the Queen Elizabeth Hospital in Birmingham where Yousafzai was treated said that although the bullet hit her left brow, it did not penetrate her skull but instead travelled underneath the skin along the side of her head and into her neck.

She was treated by doctors specializing in neurosurgery, trauma and other disciplines in a department of the hospital which has treated hundreds of soldiers wounded in conflicts in Afghanistan and Iraq.

“Malala is a strong young woman and has worked hard with the people caring for her to make excellent progress in her recovery,” said Dave Rosser, the hospital’s medical director.

“Following discussions with Malala and her medical team, we decided that she would benefit from being at home.”

Yousafzai has already been leaving the hospital on a regular basis on “home leave” in recent weeks to spend time with her parents and younger brothers, who have a temporary home in central England, Rosser said.

“During those visits assessments have been carried out by her medical team to ensure she can continue to make good progress outside the hospital,” Rosser said.

Yousafzai’s father said in October he was sure she would “rise again” to pursue her dreams after medical treatment.

(Editing by Robin Pomeroy)

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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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