Closing of Live Poultry Markets Is Called Effective in Flu Fight

Chance Chan/Reuters

Chinese doctors and nurses at a training course in April for the treatment of the H7N9 virus.

Shutting down live poultry markets is extremely effective in preventing human cases of avian flu and should be considered if the disease reappears this winter, researchers in China reported Wednesday.

But experts, including the authors, warned that shutting such markets permanently would be impractical because consumers in many countries demand live birds, and small farmers cannot afford refrigerated slaughterhouses and trucks.

Even temporary shutdowns create economic problems but should be considered, they said.

The study, published by The Lancet, concerned last spring's outbreak of H7N9 flu outbreak in southern China. The flu is still rare in humans — only 135 cases were confirmed before it disappeared in the summer, but 45 were fatal.

Two new human cases appeared in China this month, raising fears that it will surge this winter.

In four cities that responded in April by closing their live poultry markets — Shanghai, Hangzhou, Huzhou and Nanjing — human cases dropped almost immediately by 97 to 99 percent, the researchers said.

The flu first appeared in March. Most victims caught it from birds and only a few passed it on to family members or medical personnel, scientists believe.

The closed markets have all reopened, and the outbreak cost the economy an estimated $1.6 billion. It also upset the poultry industry, which is believed to have "substantial political connections," said Benjamin J. Cowling, an epidemiologist at the University of Hong Kong medical school and an author of the study.

Other experts warned that during outbreaks of H5N1 avian flu — another rare but potentially lethal influenza that has circulated since 1997 — live markets in countries like Vietnam and Egypt simply ignored orders to close. China, by contrast, is very effective at enforcing public health measures when officials decide to act.

Even in cities where refrigeration is available, many markets sell live poultry "because people like to look at the bird's color, its age, to see if it looks healthy," said Dr. Juan Lubroth, chief veterinary officer of the United Nations Food and Agriculture Organization.

Live poultry markets are often crowded and filthy; bird flu spreads in droppings, and chickens, ducks, geese and other birds often wander over floors covered with them.

Some poultry is sold live in virtually every city in the world, including New York. In poor countries, live sales are the norm because slaughtered birds spoil quickly without refrigeration.

In China, live markets "are more common than Walmart is in the U.S.," Dr. Cowling said, adding that food scandals have made consumers wary of chilled or frozen meat.

To prevent H5N1 outbreaks, some Asian cities have mandated "rest days" on which markets must be empty for 24 hours while they are cleaned and disinfected.

A study published last year of 54,000 samples of droppings collected in live bird markets over 12 years found that the presence of flu viruses on market floors could be reduced by 84 percent through several measures less punitive than full shutdowns: two monthly rest days, bans on leaving poultry in markets overnight and bans on selling quail.

Some markets require that all birds not sold by closing time must be slaughtered and disposed of. But unless sellers are compensated, they will evade those rules, said Dr. Guillaume Fournié, an epidemiologist at the Royal Veterinary College in England, who wrote a comment on The Lancet's study.

Work he did in Vietnam, Dr. Fournié said, suggested that identifying "hub" markets, cleaning them regularly and disinfecting trucks hauling birds between markets could interrupt disease transmission with fewer shutdowns.

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Contrite White House Spurns Health Law’s Critics

Stephen Crowley/The New York Times

Obama Defends Health Care Law: In Boston, President Obama vowed he would not let Republicans try to turn the health exchange website's problems into ammunition with the aim of overturning the health care law.

BOSTON — The White House on Wednesday blended expressions of contrition for the troubled rollout of its health care law with an aggressive rejection of Republican criticism of it, as the administration sought a political strategy to blunt the fallout from weeks of technical failures and negative coverage.

While Kathleen Sebelius, the secretary of health and human services, apologized profusely during a politically charged hearing on Capitol Hill, President Obama traveled to Massachusetts to argue forcefully that the Affordable Care Act will eventually be just as successful as the similar plan pioneered by Mitt Romney, his onetime rival and a former governor of the state.

Speaking in the historic Faneuil Hall, where Mr. Romney signed the Massachusetts plan into law, the president also took "full responsibility" for the malfunctioning health care website and promised to fix it. But he pledged to "grind it out" over the weeks and months ahead to ensure the law's success and prove its Republican critics wrong.

"We are going to see this through," Mr. Obama vowed, pounding his fist on the podium as the audience roared with approval.

The dual messages from Mr. Obama and Ms. Sebelius over the course of the day reflect a recognition by officials inside the White House that while apologies are in order, the administration cannot let Republicans expand concerns about the HealthCare.gov website into a broader indictment of the law.

Senior advisers to the president said they understood that the bungled rollout of the insurance marketplace has given Republicans another opportunity to litigate the political case against the health care law. But they said they viewed the weeks ahead as a period of inevitable improvement that will vindicate their position.

"The weight of that momentum will have a positive impact," one senior administration official said, requesting anonymity to talk about White House strategy planning. "Really it's about blocking and tackling and getting that work done."

With Republicans showing no sign of backing off, the challenge for Mr. Obama and Democrats in the months to come will be to deflect political attacks that unfairly demonize the health care law while acknowledging its shortcomings. Achieving that nuance could prove tricky for an administration whose top health official, Ms. Sebelius, on Wednesday called the rollout of the online insurance marketplace a "debacle."

Ms. Sebelius told lawmakers on the House Energy and Commerce Committee that she was as surprised as anyone when the website collapsed on Oct. 1 under pressure from millions of users and was crippled by technical problems in subsequent days. While she was aware of the risks in a big information technology project, she said, "no one indicated that this could possibly go this wrong."

Ms. Sebelius told the committee: "Hold me accountable for the debacle. I'm responsible."

The shift in strategy from the White House comes as new challenges emerge for the law. The problem-plagued website crashed again just before Ms. Sebelius began testifying in front of a skeptical congressional panel. And officials acknowledged that the federal insurance marketplace for small businesses, which had already been delayed a month from Oct. 1, would not open until the end of November.

In three and a half grueling hours of testimony, Ms. Sebelius gamely defended the troubled rollout of the law and apologized for what had gone wrong. But nothing she said could overcome the stark message displayed on a large video screen showing a page from HealthCare.gov: "The system is down at the moment. We are experiencing technical difficulties and hope to have them resolved soon. Please try again later."

Representative Mike Rogers, Republican of Michigan, said the administration had not properly tested the security of the insurance website, which receives financial information on consumers seeking subsidies to help pay their premiums.

Mr. Rogers read from a government memo that said security controls for the federal exchange had not been fully tested as of Sept. 27. This creates a potentially "high risk" for the exchange, said the memo, from the Centers for Medicare and Medicaid Services. The memo said that security controls would be "completely tested within the next six months."

Michael D. Shear reported from Boston, and Robert Pear from Washington.

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Well: Assessing Your ‘Fitness Age’

This article appears in the Nov. 3, 2013 issue of The New York Times Magazine.

Trying to quantify your aerobic fitness is a daunting task. It usually requires access to an exercise-physiology lab. But researchers at the Norwegian University of Science and Technology in Trondheim have developed a remarkably low-tech means of precisely assessing aerobic fitness and estimating your "fitness age," or how well your body functions physically, relative to how well it should work, given your age.

The researchers evaluated almost 5,000 Norwegians between the ages of 20 and 90, using mobile labs. They took about a dozen measurements, including height, body mass index, resting heart rate, HDL and total cholesterol levels. Each person also filled out a lengthy lifestyle questionnaire. Finally, each volunteer ran to the point of exhaustion on a treadmill to pinpoint his or her peak oxygen intake (VO2 max), or how well the body delivers oxygen to its cells. VO2 max has been shown in large-scale studies to closely correlate with significantly augmented life spans, even among the elderly or overweight. In other words, VO2 max can indicate fitness age.

In order to figure out how to estimate VO2 max without a treadmill, the scientists combed through the results to determine which of the data points were most useful. You might expect that the most taxing physical tests would yield the most reliable results. Instead, the researchers found that putting just five measurements — waist circumference; resting heart rate; frequency and intensity of exercise; age; and sex — into an algorithm allowed them to predict a person's VO2 max with noteworthy accuracy, according to their study, published in the journal Medicine & Science in Sports & Exercise.

The researchers used the data set to tabulate the typical, desirable VO2 max for a healthy person at every age from 20 to 90, creating specific parameters for fitness age. The concept is simple enough, explains Ulrik Wisloff, the director of the K. G. Jebsen Center of Exercise in Medicine at the Norwegian University and the senior author of the study. "A 70-year-old man or woman who has the peak oxygen uptake of a 20-year-old has a fitness age of 20," he says. He has seen just this combination during his research.

The researchers have used all of this data to create an online calculator that allows people to determine their VO2 max without going to a lab. You'll need your waist measurement and your resting heart rate. To determine it, sit quietly for 10 minutes and check your pulse; count for 30 seconds, double the number and you have your resting heart rate. Plug these numbers, along with your age, sex and frequency and intensity of exercise, into the calculator, and you'll learn your fitness age.

The results can be sobering. A 50-year-old man, for instance, who exercises moderately a few times a week, sports a 36-inch waist and a resting heart rate of 75 — not atypical values for healthy middle-aged men — will have a fitness age of 59. Thankfully, unwanted fitness years, unlike the chronological kind, can be erased, Dr. Wisloff says. Exercise more frequently or more intensely. Then replug your numbers and exult as your "age" declines. A youthful fitness age, Dr. Wisloff says, "is the single best predictor of current and future health."

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Well: A Fat Dad Halloween (Hide the Candy)

Every year after trick-or-treating for Halloween, I used to hide my candy in a little paisley suitcase under my bed. Just to be safe, I even locked it so my dad would not devour the contents in one night.

My sister April and I loved waiting till my parents were asleep and then pouring out our loot on the big orange, fuzzy rug (shaped like a foot) that adorned the middle of our bedroom. That foot was where we would decide what we were going to eat and what we were going to swap. After the negotiations were complete, we carefully secured our treats, locking the suitcase with a little gold key that I kept around my neck for safe keeping.

"I just can't resist the ones with caramel nougat or crispy wafers," my dad would say, as he sneaked into our room begging for something, anything — just one little bag of peanut M& M's. But days before, he had made me promise not to give in — even if he tickled me so hard that I felt as if I could not breathe. "The goblins are going to get you, the goblins are going to get you," he would repeat in an animated voice, trying to wear me down so I would surrender my candy. "Feed me, feed me," he begged, inhaling the candy aroma left behind on an empty wrapper he found on the bedroom floor. I knew he would be furious with both himself and me the next morning if I did not hold up my end of the bargain.

In my house, food and affection were inextricably tied. My father, a successful advertising executive, usually weighed around 350 pounds but his weight could often fluctuate a hundred pounds on either end as he tried (and failed) almost weekly to attempt the latest fad diet. My mother, meanwhile, was a finicky eater who rarely sat down to family meals.

I remember Halloween being an especially difficult holiday for my dad, who had spent six months at Duke University's "Fat Farm" where he had lost 175 pounds avoiding sugar, salt and fat. Before that diet, he would sometimes gobble three candy bars in a row. "There is nothing like the smell of real milk chocolate," he would say, reminiscing about his favorite candy bars: Butterfingers, Kit Kats, and Three Musketeers.

My dad called Halloween a fabulous marketing trick not only for the candy companies, but for the diet industry. The holiday set up candy-lovers to indulge for days, gorging on buckets of left over candy. Once the candy was gone, the guilt set in and the candy eaters began looking for quick solutions to make up for the binge. Sales of bagged candy treats were soon replaced by sales of diet sodas, pills, and weight loss shakes.

Despite my dad's love-hate relationship with Halloween, I loved it. For me, trick-or-treating was about more than the candy. It was a chance to pretend to be Raggedy Ann, a wild alley cat, or a devil– anyone but me. I was just as happy to receive stickers or coins for my UNICEF box as a candy bar. The fun was about being with my friends, carving pumpkins, running up and down the streets, and contemplating for weeks what my costume would be. I loved ringing doorbells, chanting, "Trick or Treat, smell my feet, give me something good to eat!"

I waited with anticipation for the doors to open and see who was going to answer, and what they would drop into my plastic, orange pumpkin. The more unexpected, the better. My favorites were always the nonedible prizes like plastic spider rings, or the silly putty eggs, or big red wax lips.

When I went to my friend Monica's house in the West Village, where we would go for an after school party before the big Halloween parade, I marveled at how all my friends transformed themselves, and how much detail her dad put into decorating their house. Halloween at Monica's came with scary jack–o'-lanterns, ghosts project on the wall, a bowl of smoking red punch that filled the room like fog, and orange cobwebs with hanging spiders that dangled in every doorway. They even had creepy music and a big caldron where we bobbed for apples. We snacked on Deviled Eye Balls, Dead Man Finger Sandwiches and Black Snake Spaghetti. I admired the creativity of their menu, and I was in heaven, smelling the pumpkin seeds roasting, the warm apple cider simmering, and chocolate zucchini muffins baking.

The smell of home cooking always reminded me of my grandmother, Beauty. For as long as I can remember, Beauty taught me how to appreciate the aromas of food and feel nourished when something warm and homemade was served to me. Sometimes that included sweets, like her homemade peanut butter fudge or chocolate turtle crunchies. I always preferred Beauty's homemade treats to the kind that came in wrappers at Halloween (except for Now & Laters, which I adored.) For me, Halloween candy served as a way to barter. In sixth grade, you could trade something rare like a Charleston Chew or a Sugar Baby for a Wacky Pack Sticker or a Matchbox car. Each candy had a different value based on who you were trying to trade with. I would swap most of my bag, trying to get a rare collectable such as a Ghostess Fright Pie or a Skimpy Peanut Buttter sticker to decorate my notebook.

At night I would listen to the sounds of my father in the kitchen – the opening of the refrigerator door, drawers banging, and cabinets creaking. Taking the key off my neck, I would check my candy stash at night, planning for the next day's bartering. When I was finished, I pushed the little suitcase back under my bed.

My dad was always amazed how I could trade my candy away. But he never seemed to realize that candy was not what I craved.

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Beauty's Chocolate Turtle Crunchies
My grandmother used to make these candies when she wanted something sweet but without a lot of added sugar. These crunchy treats take little time or skill to prepare.

Ingredients:
½ cup of toasted pecans, chopped
½ cup soft dates, chopped
½ cup organic cornflakes
1 cup semi sweet chocolate chips
½ teaspoon of vanilla

Directions:

1. Chop the dates and nuts. Toss them into a bowl with the cornflakes.
2. Gently melt the chocolate chips on top of a double boiler and add the vanilla
3. Pour chocolate into the bowl and stir all ingredients together.
4. Drop the mixture onto parchment paper using a small tablespoon. Press down lightly with the back of a fork or shape by hand.
5. Chill in the refrigerator for one hour.

Yield: 12 Servings

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Well: Quit Smoking? It’s Probably Monday

If you are thinking of quitting smoking, it is probably Monday.

Researchers monitored Google search queries from 2008 to 2012 in English, French, Chinese, Portuguese, Russian and Spanish. Almost every week, queries about smoking cessation peaked on Mondays.

The study, published Monday in JAMA Internal Medicine, found that during the study period, the number of queries in English on Mondays was 1 percent larger than on Tuesdays, 11 percent larger than Wednesdays, 22 percent larger than Thursdays, 67 percent larger than Fridays, 145 percent larger than Saturdays and 59 percent larger than Sundays. Only in Russian did Monday queries come in second to Sunday.

"Monday is also the day you're more likely to get a headache, the flu, a stroke," said the lead author, John W. Ayers, a research professor at the San Diego State University Graduate School of Public Health. "Is there a biological explanation, a sociological one? It could be the interaction of both."

Though the reasons remain unknown, Dr. Ayers said, it may be that antismoking advertising should concentrate on the times when people are most likely to be thinking of quitting. This kind of information, he said, "has immediate import for how we manage public health interventions."

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This post has been revised to reflect the following correction:

Correction: October 28, 2013

An earlier version of this article misidentified the journal source. It is JAMA Internal Medicine, not Journal of the American Medical Association.

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The New Old Age: Two Kinds of Hospital Patients: Admitted, and Not

Judith Stein got a call from her mother recently, reporting that a friend was in the hospital. "Be sure she's admitted," Ms. Stein said.

As executive director of the Center for Medicare Advocacy, she has gotten all too savvy about this stuff.

"Of course she's admitted," her mother said. "Didn't I just tell you she was in the hospital?"

But like a sharply growing number of Medicare beneficiaries, her mother's friend would soon learn that she could spend a day or three in a hospital bed, could be monitored and treated by doctors and nurses — and never be formally admitted to the hospital. She was on observation status and therefore an outpatient. As I wrote last year, the distinction can have serious consequences.

The federal Centers for Medicare and Medicaid Services tried to clarify this confusing situation in the spring with a policy popularly known as the "two-midnight rule." When a physician expects a patient's stay to include at least two midnights, that person is an inpatient whose care is covered under Medicare Part A, which pays for hospitals. If it doesn't last two midnights, Medicare expects the person to be an outpatient, and Part B, which pays for doctors, takes over.

It's rare to have hospital and nursing home administrators, physicians and patient advocates all agreeing about a Medicare policy, but in this case "there's unanimity of dislike," said Carol Levine, director of the Families and Health Care Project of the United Hospital Fund. Despite protests, the rule took effect on Oct. 1, but Medicare agreed to delay penalties for 90 days.

Meanwhile, administrators at the Johns Hopkins Hospital in Baltimore have taken to calling the policy the Cinderella Rule, said Amy Deutschendorf, senior director of clinical resource management: "If you cross two midnights, you're an inpatient. If not, you're a pumpkin."

Being a pumpkin can cost patients a lot of money. Under Part B, they're billed separately for every procedure and visit and drug, and the co-pays can mount until patients owe hundreds or thousands of dollars — which they may only discover upon receiving the bills. "People are shocked," Ms. Levine said. "Nobody is required to tell them they're outpatients." (Except in New York State, where the governor just signed legislation requiring that Medicare beneficiaries be informed of their observation status and be able to appeal it.)

More expensive, though, are the fees at rehab places or nursing homes, which Medicare will pay for after three days of inpatient care. Those who've been outpatients don't qualify for that benefit and can find themselves on the hook for five-figure sums.

So patients are complaining, and so are hospitals. Older people in emergency rooms often have complex problems, and they are strangers to the physicians who must decide whether to admit them or not. "Nobody looking at the patients who come through the door can predict who's going to be here for two midnights," Ms. Deutschendorf said. Yet a hospital that admits patients who don't need two midnights' worth of care may face Medicare audits, denied payments, fraud accusations and financial penalties.

Johns Hopkins at least gives observation patients an information sheet telling them they're outpatients, to forestall later shock. But "it causes them angst and results in deteriorating patient-physician relationships," Ms. Deutschendorf said. She estimated that under the new rule, observation stays will double. "We don't want to be the bad guys here," she said.

Hospitals will lose money, too, it appears, since Part A reimburses at higher rates than Part B. An 18-month study of observation patients at the University of Wisconsin Hospital, recently published in JAMA Internal Medicine, found that they accounted for more than a quarter of adult general medicine stays. The hospital lost about $500 for each adult general medicine inpatient (the difference between cost and reimbursement); for observation patients, it lost nearly $1,400. Other studies have found that observation costs less, however.

Money matters, of course, but opponents of the two-midnight rule also point out that it lacks logic. "Hospital care is hospital care," Ms. Deutschendorf said. But not always.

Say Patient X arrives at the emergency room complaining of chest pains at 11:58 p.m. on Tuesday and gets discharged from the hospital on Thursday morning after breakfast. Patient X will have stayed for two midnights, so he was an inpatient, covered by Medicare Part A.

Say Patient Y arrives with the same condition five minutes later, at three minutes past midnight on Wednesday morning, and also leaves Thursday. Patient Y stayed only one midnight, so even if he received precisely the same care, he's a pumpkin, facing higher Part B co-pays.

Moreover, if Patient X receives medically necessary services and gets discharged Friday morning instead of Thursday, he will have stayed three days, and so Medicare will cover rehab care if he can't safely go home. Patient Y has been an outpatient, so even after three days, he'll have to pay for rehab himself.

What patient advocates really want is to get rid of that three-day hospitalization requirement for the Medicare nursing home benefit. But the odds don't look encouraging. Last month, a federal court in Connecticut dismissed a class-action suit brought by the Center for Medicare Advocacy and the National Senior Citizens Law Center, seeking to overturn the rule. They have decided to appeal. (Therefore, federal officials at Centers for Medicare and Medicaid Services will not comment.)

Legislation to allow any time spent in a hospital — as an inpatient or outpatient or both — to count toward the three-day requirement for skilled nursing coverage has gone nowhere in two Congresses, but it has acquired more than 100 House sponsors from both parties and more than 20 in the Senate. That may be the more likely situation, someday.

Meanwhile, families should at least ask, as the staff members fasten the plastic ID bracelet around a relative's wrist: Is she an inpatient? Or an outpatient?

---

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

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This post has been revised to reflect the following correction:

Correction: October 29, 2013

Because of an editing error, an earlier version of this post referred incorrectly to the organization whose officials declined to comment on a pending class-action suit. It is the federal Centers for Medicare and Medicaid Services, not the Center for Medicare Advocacy.

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In Practice: People Who Buy Own Health Policies Face Big Changes

As Washington and much of the rest of the nation debate whether President Obama misled Americans when he said that people who like their health plans may keep them, tens of millions of people are finding that their insurance is largely unchanged by the new health care law.

They are the estimated 149 million people who receive health insurance through an employer, according to the Kaiser Family Foundation. While the law has required adjustments to those plans and some prices could rise, generally people who keep their jobs may keep the same coverage. Some exceptions exist.

The story is different for the 10 million to 12 million people who buy insurance on their own. Rules for those policies have changed substantially for 2014.

Insurers are informing many of those people that their old plans have been discontinued and that they must choose new plans at new prices.

About half of those people may qualify for federal subsidies or Medicaid, according to a recent analysis from the Kaiser Family Foundation. But those who do not are often facing much higher premiums.

The coverage required under the federal health care law is much more generous than many of the plans that had been sold to individuals, and insurers are now pricing these policies to account for many of the older and sicker people they once could turn away but must now cover. Under the new rules, people with pre-existing conditions may not be denied coverage and there are limits on how much prices may vary for people of differing ages.

Some people may find a new policy less expensive than their previous one. That could be because the insurer charged a high premium based on their age or medical condition. That is no longer permitted. And others may have plans that are "grandfathered," meaning they were in place in 2010 and can be renewed without significant changes.

At Florida Blue, for example, 300,000 people will be notified this year that their coverage is up for renewal, and they will have to select a new plan, either through the new state marketplace or directly with the insurer. Only about 60,000 will be allowed to renew their current policies because they are grandfathered. The rest must choose among the new plans offered by Florida Blue or another insurer.

"There's always been a lot of churn in the individual market," said Jon Urbanek, a senior executive at Florida Blue. As a result, most people will be told that they need to change policies when they would typically be asked to renew, he said. "We're not terminating their coverage," he said, but people will be asked to change their policies and pay whatever premiums are being charged for that particular plan. "They're renewing into these qualified health plans."

About 40,000 people have received letters informing them that their policies end in January, he said, but the bulk of people tend to renew later in the year.

As part of the law, certain benefits must be included in the new policies. For example, coverage must include maternal care.

While many people may find coverage in the current open enrollment period, which ends March 31, they can still get coverage when their current policy ends.

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Well: The Marathon Runner as Couch Potato

Phys Ed

Gretchen Reynolds on the science of fitness.

Someone can train for a marathon and simultaneously qualify as a couch potato, recent research shows, raising provocative questions about how sedentary most of us really are.

The amount of time that most of us spend sitting has increased substantially in recent decades, especially as computers and deskbound activities have come to dominate the workplace. According to one telling recent study, the average American sits for at least eight hours a day.

Such prolonged sedentariness may have health consequences, additional research shows. A study of almost 2,000 older adults published in August, for instance, found that those who spent the most hours seated every day had a greater risk of high blood pressure, elevated blood sugar, a poor cholesterol profile and body-wide inflammation than those who sat the least, no matter how much either group exercised (which, generally, was not much).

So, too, a stark numerical 2012 analysis of lifestyle, health and death statistics from a large group of Australian adults concluded that every hour that someone spent watching television — a widely accepted marker of sitting time — after the age of 25 reduced his or her lifespan by almost 22 minutes. More broadly, in this analysis, watching television for six hours or more per day shaved almost five years from a typical adult's lifespan, compared with someone who did not watch TV. Lifespan was shortened even if someone met the standard medical recommendation of exercising moderately for 30 minutes or so on most days of the week.

But many highly active people, including those completing their preparations for Sunday's upcoming New York City Marathon, likely feel immune from such concerns. After all, it seems reasonable enough to assume that multiple hours spent training must lessen the number of hours spent plopped in a chair.

Until recently, however, no studies had specifically examined whether people who are extremely active are, on the whole, also truly not sedentary.

So scientists affiliated with the School of Public Health at the University of Texas at Austin recently set out to fill that research gap. They began by contacting runners who had signed up for the local Austin marathon or half-marathon. More than 200 of the race entrants, male and female, agreed to participate.

The Texas researchers asked these volunteers to complete a questionnaire that precisely parsed how they spent their time each day. "We didn't want to look only at certain measures" of sitting time, such as television viewing, said Geoffrey Whitfield, who devised the study as a doctoral student at the University of Texas.

Instead, the questionnaire asked about work, commuting, and telephone habits, as well as time spent watching television or playing computer games. It also asked the volunteers to enumerate how many hours they spent training each day and their anticipated race pace.

As expected, the runners, training as they were for a marathon or half-marathon, reported spending considerable time sweating. On average, they exercised vigorously for nearly seven hours per week, "which far exceeds the standard exercise recommendation," said Dr. Whitfield, who is now an Epidemiological Intelligence Service Officer at the Centers for Disease Control and Prevention in Atlanta.

But those hours of exercise do not seem to have reduced sedentary time. On an average workday, the runners reported sitting for more than 10 hours at the office and at home, easily topping the likely national average. (Almost all of the participants were employed; a few were students.) On non-workdays, the runners spent about eight hours inactive.

The researchers found no correlation between running pace or training volume and sedentary time; fast runners and slow runners both sat equally often, as did those who were putting in the most or the fewest hours each week training.

In effect, the data showed that "time spent exercising does not supplant time spent sitting," said Harold Kohl, a professor of epidemiology and kinesiology at the University of Texas and senior author of the study. "It seems that people can be simultaneously very active and very sedentary."

The study does not necessarily intimate, however, that being a marathon runner and couch potato is in any particular way harmful, Dr. Kohl pointed out. He and his colleagues did not measure the runners' health, he said, only their lifestyle. "It is impossible to say" based on their data, whether heavy training would ameliorate any undesirable effects of sitting or whether such effects even would occur in the supremely fit.

Still, the findings are a cautionary reminder that many of us, including the most physically active, may be more sedentary than we imagine. "The fact is that exercise, even at very high doses, does not occupy much time in most people's days," said Dr. Whitfield, who himself used to train for triathlons. And while the science about the health impacts of prolonged sitting may still be incomplete, he said, "it's pretty safe to say that it would a good idea for most of us to spend more of our time up and moving."

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Generic Rivals Sharply Erode Merck’s Results

Merck reported on Monday that its third-quarter profit plunged 35 percent because of competition from generic drugs, lower sales of its top-selling medicine, and restructuring and acquisition charges.

The results still beat Wall Street's profit expectations, but the drug maker sharply lowered its forecast for the full year.

Generic competition continues to weigh on Merck's asthma and allergy pill, Singulair, cutting sales 53 percent, to $280 million. The drug brought in $5.5 billion each year until its patent expired in August 2012 and cheap copycat versions flooded the market.

Merck had previously weathered generic competition to its blockbusters, usually managing to keep total sales about the same level as before big patent expirations.

"This year, we were not able to do that," the company's chief executive, Kenneth C. Frazier, said on Monday.

Merck's net income was $1.12 billion, or 38 cents a share, down from $1.73 billion, or 56 cents a share, in the period a year earlier.

The company said earnings would have been $2.73 billion, or 92 cents a share, excluding charges of $1.2 billion for merger and integration costs and $967 million for restructuring costs. Analysts surveyed by FactSet were expecting 88 cents a share.

Revenue in the quarter totaled $11.03 billion, down 4 percent and below analysts' expectations for $11.13 billion.

Besides Singulair, Merck is being hurt by generic versions of a half-dozen other drugs, plus unfavorable currency exchange rates, and its newer medicines are not picking up all the slack. Merck said it now expects total 2013 sales to be down 5 percent to 6 percent from last year.

Its top seller, Type 2 diabetes pill Januvia, had been climbing steadily toward the $4 billion-a-year mark, but sales slipped 5 percent in the quarter.

"Big, ugly surprise in revenues," concluded Erik Gordon, an analyst and professor at the Ross School of Business at the University of Michigan. "It's a contrast to their sisters in Big Pharma, who have been coming close to hitting their projections."

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With Suit, Parents of Boy With Seizures Press Arizona Officials on Marijuana Act

David Kadlubowski for The New York Times

Jennifer and Jacob Welton, with their son Zander, 5, in Mesa, Ariz., want marijuana resins made legal.

PHOENIX — Arguing that medical marijuana has been the most effective treatment for their son's seizure disorder, the parents of a 5-year-old boy filed a lawsuit here on Monday to force state officials to include marijuana extracts — oil-like resins with very low levels of the psychoactive ingredient THC — as a legal product under the state's medical marijuana act.

As it stands, the act, approved by voters in 2010, allows patients to use "any mixture or preparation" made with dried marijuana flowers, like brownies. The boy's parents, Jacob and Jennifer Welton, have been crushing the flowers and mixing them into applesauce, which they say has become difficult for the boy to ingest after brain surgery last year compromised his ability to eat. They do not want to buy the extract, found on the black market, for fear of being arrested.

"We're not criminals," Ms. Welton, 30, an enrollment adviser at the University of Phoenix, said in an interview. "We just want what's best for our son."

The Weltons' legal action opens a new front on the fight over legalizing marijuana for medicinal use across the country, focusing on very sick children to highlight its potential benefits.

Arizona's statute has no age restrictions; patients under 18 can use medical marijuana as long as a parent or legal guardian is told of its potential risks and is in charge of buying and administering it, among other requirements.

But the Maricopa County attorney, Bill Montgomery, has said that patients can be criminally prosecuted for using extracts and other products that do not meet the definition of "cannabis" under the state's criminal code, which treats resin extracted from marijuana as an illegal narcotic. The couple lists Mr. Montgomery, Gov. Jan Brewer and Will Humble, the director of the Arizona Department of Health Services, as defendants in its lawsuit.

"We're taking a proactive measure," said Emma A. Andersson of the American Civil Liberties Union's Criminal Law Reform Project and the Weltons' lead lawyer. "Rather than waiting for these parents to be criminally prosecuted, we're asking the courts to clarify what the medical marijuana law is."

The Weltons' approach has already scored victories and forged alliances in unlikely corners. In August, Gov. Chris Christie of New Jersey, which has one of the nation's strictest marijuana statutes, allowed dispensaries to provide edible products made with marijuana leaves or extract to children. On Monday in Michigan, State Representative Mike Shirkey, a Republican, introduced legislation that would add edible products and extracts to the list of products deemed "usable" under the state's medical marijuana law, approved by voters in 2008.

Utah does not have a medical marijuana program, but a Republican legislator there, State Representative Gage Froerer, plans to propose a bill allowing the use of extracts to treat children.

In an interview, Mr. Froerer said, "With these low THC levels and the research I found coming from Colorado" and other states where the extracts are legal, "you ask yourself, if this was one of your kids, would you want this product available?"

Through representatives, the defendants declined to comment while litigation was pending. Still, in a recent blog post, Mr. Humble talked about the confusion caused by the different definitions of marijuana and cannabis in the state's medical marijuana law and criminal code, saying that patients who use medical marijuana and the dispensaries that sell to them "may be exposed to criminal prosecution" if they have "resin extracted from any part" of a marijuana plant.

Mr. Montgomery, in a wide-ranging news conference last month, said one of his concerns was that the medical marijuana law sets limits only on dispensing dried marijuana — 2.5 ounces per patient every 14 days — making it hard to regulate the sale of resins and oils.

Last week, the Food and Drug Administration approved the country's first studies on the marijuana compound cannabidiol, a nonpsychoactive marijuana component, as an antiseizure medication. Some scientists believe the compound quiets the electrical and chemical activities in the brain that trigger seizures. Extracts are often heavy on cannabidiol, with a negligible amount of THC.

The parents of Zander, the 5-year-old boy here, decided to request medical marijuana for him after watching a CNN documentary featuring the story of a girl from Colorado whose seizures fell to a handful over eight months from about 300 per week. At that time, Zander, who has cortical dysplasia, a genetic defect, was facing the prospect of a third brain surgery.

His daily seizures, which started when he was 9 months old, had made him unresponsive to emotional and physical prompts, Ms. Welton said. He was first given medical marijuana seven weeks ago, and since then he has been able to stand straighter, stack blocks and walk backward for the first time.

Ms. Welton said extracts, in addition to being easier to ingest, can be taken in more precise doses than the plant.

"We tried so many other regular pharmaceutical medications. They don't have the same stigma, but they didn't help him and sometimes they made him worse," said Ms. Welton, who has two other children. "I wouldn't want any of my other kids using marijuana. But this is Zander's medication, and for the first time, I feel like there's hope for him."

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Ohio Governor Defies G.O.P. With Defense of Social Safety Net

Ty William Wright for The New York Times

Gov. John R. Kasich of Ohio said of fellow Republicans in Washington, "I'm concerned about the fact there seems to be a war on the poor."

COLUMBUS, Ohio — In his grand Statehouse office beneath a bust of Lincoln, Gov. John R. Kasich let loose on fellow Republicans in Washington.

"I'm concerned about the fact there seems to be a war on the poor," he said, sitting at the head of a burnished table as members of his cabinet lingered after a meeting. "That if you're poor, somehow you're shiftless and lazy."

"You know what?" he said. "The very people who complain ought to ask their grandparents if they worked at the W.P.A."

Ever since Republicans in Congress shut down the federal government in an attempt to remove funding for President Obama's health care law, Republican governors have been trying to distance themselves from Washington.

Gov. Scott Walker of Wisconsin schooled lawmakers in a Washington Post opinion column midway through the 16-day shutdown on "What Wisconsin Can Teach Washington." Gov. Chris Christie of New Jersey, with a record of bipartisan support at home, remarked after a visit to the nation's capital, "If I was in the Senate right now, I'd kill myself."

But few have gone further than Mr. Kasich in critiquing his party's views on poverty programs, and last week he circumvented his own Republican legislature and its Tea Party wing by using a little-known state board to expand Medicaid to 275,000 poor Ohioans under President Obama's health care law.

Once a leader of the conservative firebrands in Congress under Newt Gingrich in the 1990s, Mr. Kasich has surprised and disarmed some former critics on the left with his championing of Ohio's disadvantaged, which he frames as a matter of Christian compassion.

He embodies conventional Republican fiscal priorities — balancing the budget by cutting aid to local governments and education — but he defies many conservatives in believing government should ensure a strong social safety net. In his three years as governor, he has expanded programs for the mentally ill, fought the nursing home lobby to bring down Medicaid costs and backed Cleveland's Democratic mayor, Frank Jackson, in raising local taxes to improve schools.

To some Ohio analysts, those moves are a reaction to the humiliating defeat Mr. Kasich suffered in 2011 when voters in a statewide referendum overturned a law stripping public employees of bargaining rights. Before the vote, Mr. Kasich's approval in this quintessential swing state plunged.

Now, as the governor's image has softened, his poll numbers have improved heading into a re-election race next year against the likely Democratic nominee, Ed FitzGerald, the executive of Cuyahoga County.

He still angers many on the left; he signed a budget in June that cut revenues to local governments and mandates that women seeking an abortion listen to the fetal heartbeat. Democrats see his centrist swing as mere calculation, a prelude to a tough re-election fight.

"This is someone who realized he had to get to the center and chose Medicaid as the issue," said Danny Kanner, communications director of the Democratic Governors Association. "That doesn't erase the first three years of his governorship when he pursued polices that rewarded the wealthy at the expense of the middle class."

Ohioans earning in the top 1 percent will see a $6,000 tax cut under the latest budget passed by the Republican-led legislature, while those in the bottom fifth will see a $12 increase, according to Policy Matters Ohio, an independent research group.

The governor dismissed the notion that his Medicaid decision was political. "I have an opportunity to do good, to lift people, and that's what I'm going to do," he said. "You know what?" he added, using a phrase he utters before aiming a jab. "Let the chips fall where they may."

The son of a mailman who grew up outside Pittsburgh, Mr. Kasich (pronounced KAY-sik) has said he didn't meet a Republican until he arrived as a freshman at Ohio State. He has often showed an independent streak. He supported President Bill Clinton's assault weapons ban while in Congress in 1994, and he teamed with Ralph Nader to close corporate tax loopholes.

In the interview in his office, he criticized a widespread conservative antipathy toward government social programs, which regards the safety net as enabling a "culture of dependency."

Mr. Kasich, who occasionally sounds more like an heir to Lyndon B. Johnson than to Ronald Reagan, urged sympathy for "the lady working down here in the doughnut shop that doesn't have any health insurance — think about that, if you put yourself in their shoes."

He said it made no sense to turn down $2.5 billion in federal Medicaid funds over the next two years, a position backed by state hospitals and Ohio businesses.

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Health Site Puts Agency and Leader in Hot Seat

Kevin Lamarque/Reuters

Marilyn Tavenner, at a Senate hearing in April, leads the agency that oversaw the creation of the troubled health care website.

WASHINGTON — Ten days before HealthCare.gov opened for business, Marilyn Tavenner, the obscure federal bureaucrat whose agency oversaw the creation of the troubled online insurance marketplace, had a bad omen. It was a Sunday, and her mobile device was on the fritz, forcing her to go into the office.

"It reminded me that I can still be brought to my knees by a malfunctioning BlackBerry," she joked in late September, recounting her technology woes to a group of insurance executives.

Nobody at the Centers for Medicare and Medicaid Services, the agency Ms. Tavenner runs, is joking now.

On Tuesday, she will be on Capitol Hill to face a grilling from House Republicans over the website's failures. It will be an unusual turnabout for Ms. Tavenner, 62, who was confirmed overwhelmingly by the Senate in May on a bipartisan 91-to-7 vote and had the enthusiastic backing of the House Republican leader, Representative Eric Cantor, who knows her from her days as health secretary in his home state, Virginia.

Her testimony, before the House Ways and Means Committee, will serve as a warm-up for that of her boss, Kathleen Sebelius, the health and human services secretary, who will appear before another House panel on Wednesday. Republicans, who have scheduled a series of hearings to examine the problems with the troubled website, have demanded that someone in the Obama administration be held accountable for the problem-plagued rollout.

"There's a lot of fault to go around when it comes to the launch of the Obamacare exchanges, least of which is trying to figure out who was in charge," said Senator Orrin G. Hatch, Republican of Utah, who voted to confirm Ms. Tavenner. Referring to Ms. Tavenner's agency and to the Health and Human Services Department, he added, "Was it C.M.S.? Was it H.H.S.? Was it the White House? That it's this hard to unravel is unacceptable."

While the Medicare and Medicaid agency has major responsibility for carrying out the president's health care overhaul, there have been hints that Ms. Tavenner was kept out of the loop on some critical decisions.

In July, after the Obama administration announced it was delaying the so-called employer mandate — a requirement that companies with more than 50 employees contribute to the cost of insurance or pay a penalty — Ms. Tavenner told lawmakers that she had been on vacation when the decision was announced and had no part in it.

"I was not consulted," she said.

A onetime nurse and hospital executive, Ms. Tavenner came to Washington in 2010 to serve as deputy to Dr. Donald M. Berwick, President Obama's first, and controversial, pick to run the sprawling agency. After Dr. Berwick, who became a symbol of Republican discontent about Mr. Obama's health policies, was unable to win Senate confirmation, Ms. Tavenner took over in an acting capacity in December 2011. This year, she became the agency's first Senate-confirmed administrator since 2006.

Ms. Tavenner was not available for an interview on Monday.

Republicans said they expected to press Ms. Tavenner on a range of issues, including how many people have signed up for insurance through the online exchanges and how hands-on she was in monitoring the development of the website and managing the various federal contractors on the project.

Representative Dave Camp, a Michigan Republican and the chairman of the Ways and Means Committee, said through a spokeswoman that he viewed Ms. Tavenner as "a serious witness" who would "shed light on the systemic failures that led up to the rollout."

But Democrats expect Republicans to use Ms. Tavenner's testimony mostly to lay the groundwork for tougher treatment of Ms. Sebelius, who some Republicans have said should resign.

"Clearly, the launch has had some substantial problems," said Representative Sander M. Levin of Michigan, the senior Democrat on the committee, "but I think the basic difference here is Democrats want to make it work and Republicans don't."

In recent days, press officers for Ms. Tavenner's agency have been fending off questions about whether she foresaw problems and whether she notified Ms. Sebelius. On Monday, asked to describe the chain of command for work on the Affordable Care Act, a spokeswoman, Julie Bataille, said the agency took responsibility. "Our administrator has been in charge of our overall A.C.A. implementation effort," she said.

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F.D.A. Shift on Painkillers Was Years in the Making

When Heather Dougherty heard the news last week that the Food and Drug Administration had recommended tightening how doctors prescribed the most commonly used narcotic painkillers, she was overjoyed. Fourteen years earlier, her father, Dr. Ronald J. Dougherty, had filed a formal petition urging federal officials to crack down on the drugs.

Jonathan Ernst for The New York Times

Senator Joe Manchin III, Democrat of West Virginia, backed limits on prescription painkillers.

Dr. Dougherty told officials in 1999 that more of the patients turning up at his clinic near Syracuse were addicted to legal narcotics like Vicodin and Lortab that contain the drug hydrocodone than to illegal narcotics like heroin.

Since then, narcotic painkillers, or opioids, have become the most frequently prescribed drugs in the United States and have set off a wave of misuse, abuse and addiction. Experts estimate that more than 100,000 people have died in the last decade from overdoses involving the drugs. For his part, Dr. Dougherty, who foresaw the problem, retired in 2007 and is now 81 and living in a nursing home.

"Too many lives have been ruined," his daughter said.

The story behind the F.D.A.'s turnaround on the pain pills, last Thursday, involved a rare victory by lawmakers from states hard hit by prescription drug abuse over well-financed lobbyists for business and patient groups, one that came during a continuing public health crisis.

Just last year, Representative Fred Upton, Republican of Michigan — the House's biggest recipient during the last election cycle of drug industry campaign contributions, with nearly $300,000 — blocked a measure that would have imposed the restrictions the F.D.A. backed last week.

Among the provisions in the bill, pushed by Senator Joe Manchin III, Democrat of West Virginia, was one that is central to the new F.D.A. recommendations: reducing to 90 days the length of time in which a patient could obtain refills for painkillers containing hydrocodone without a doctor visit. The drugs are now widely sold by generic producers.

Mr. Upton, who is the chairman of the House Energy and Commerce Committee, argued that imposing new limits would harm patients who needed the drugs, which are used to treat pain from injuries, arthritis, dental extractions and other problems. That stance was echoed by patient groups, lobbyists representing drug makers, pharmacy chains like Walgreens and CVS, local drugstores and physicians groups like the American Medical Association.

The F.D.A.'s long resistance to added restrictions on the drugs underscores what critics say is its continuing struggle to address the complexities of the painkiller problem in its often conflicting roles — one as a regulator that approves drugs and the other as a drug safety watchdog.

On Friday, public health advocates who had cheered the agency's decision the day before were dismayed when the F.D.A. approved a new, high-potency painkiller despite an 11-2 vote by an expert panel of its own advisers not to do so. The panel concluded in December that the long-acting opioid, called Zohydro, could lead to the same type of abuse and addiction as OxyContin.

A top F.D.A. official, Dr. Douglas Throckmorton, said Zohydro would give doctors another drug to treat long-term pain. But Representative Harold Rogers, Republican of Kentucky, said on Friday that top F.D.A. officials had recently assured him they would only approve new opioids like Zohydro if they were marketed in formulations intended to deter abuse. OxyContin is now formulated that way, but Zohydro, which is contains hydrocodone without acetaminophen, is not. Its producer, Zogenix, says it will closely monitor use of the drug.

"It is like the original OxyContin, so that is real problematical," Mr. Rogers said.

It was in 1999 that Dr. Dougherty noticed there was something unusual about the regulations governing the pain pills to which his patients were becoming addicted.

Hydrocodone, the active narcotic in the pills, faced tighter prescribing restrictions if used alone than if it was contained in a medication that combined it with acetaminophen, an over-the-counter painkiller found in products like Tylenol.

Controlled substances are overseen by the Drug Enforcement Administration, which classifies drugs and their prescribing rules into categories called schedules based a medication's potential for abuse. In the 1970s, drug companies successfully argued to Congress that Vicodin and similar products should be placed in a less restrictive category known as Schedule III because the use of over-the-counter drugs like acetaminophen in them would reduce their misuse and increase their effectiveness.

Schedule III drugs are easier for doctors to prescribe and for patients to refill than those considered to pose the highest abuse risk, which are placed in Schedule II. For example, patients can get refills for a Schedule III drug for as long as six months before seeing a doctor again, twice as long as for a Schedule II drug. Also, drugstores face tighter and more costly storage and record-keeping requirements for Schedule II drugs.

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Health Site’s Woes Could Dissuade Vital Enrollee: the Young and Healthy

Gabriella Demczuk/The New York Times

Organizing For Action workers in Arlington, Va., inform the public about the launch of Obamacare on Oct. 1.

WASHINGTON — Sean Jackson, like tens of thousands of other Americans, has had trouble signing up for medical coverage using the HealthCare.gov insurance marketplace, despite several attempts.

"I was able to create an account on Oct. 2, and I haven't been able to get into there since," said Mr. Jackson, a sports journalist living in Ohio, a note of annoyance in his voice. "I'll try at random times, like late at night or early in the morning. I sign in. It just goes to a blank screen."

The economists and policy wonks behind the Affordable Care Act worry that the technical problems bedeviling the federal portal could become much more than an inconvenience. If applicants like Mr. Jackson decide to put off or give up on buying coverage, rising prices and even a destabilized insurance market could result.

The enrollment of people like Mr. Jackson, who is 32, is vital for the health care law — and, for that matter, the entire health care system — to work. Younger people, who tend to have very low anticipated medical costs, are supposed to help pay for the medical costs of older or sicker enrollees. Without them, so-called risk pools in Ohio and other states might become too risky, forcing insurers to raise premiums. Those higher premiums could dissuade more of the young and healthy from signing up, forcing insurers to raise prices again.

Economists call the process "adverse selection" and warn that in its worst iteration it could lead to a "death spiral" of falling enrollment and climbing prices.

Economists and health analysts said the chances of such a spiral were slim in most states because Americans who go without insurance would face penalties, starting next year. But they said that the endemic problems with the Web site posed a serious question about the enrollment balance in many state plans.

"If there are significantly more of the older and higher-cost people purchasing coverage than are expected, that's going to have a significant impact on premiums for the following year," said Robert Zirkelbach, a spokesman for America's Health Insurance Plans, a lobbying group for insurers covering 200 million Americans. He added, "It could ultimately destabilize the market."

The young and healthy have always been seen as crucial to making the health law work, and the Obama administration and many state governments have focused on getting them to sign up.

For the White House, that has meant using the demographic microtargeting techniques used during the 2008 and 2012 presidential campaigns to identify and reach young people in the hope that they would make up about 40 percent of new enrollees in the health exchanges. For Colorado, it has meant creating an advertisement showing "bros" drinking beer while celebrating insurance coverage. "Keg stands are crazy," the ad reads. "Not having health insurance is crazier."

But getting "young invincibles," as insurers sometimes call them, to sign up for insurance is an uphill climb. Even with the public campaigns, only about one in four 19- to 29-year-olds is even aware of the exchanges where they might buy affordable insurance, and the ignorance is especially acute among the uninsured, according to a survey this year by the Commonwealth Fund, a nonprofit research group.

"There's very low awareness among young adults," said Sara R. Collins, an economist with the Commonwealth Fund. "It's a concern in states that aren't actively promoting these exchanges. People might remain unaware," she said, referring to the 36 states that have opted to let the federal government run their exchanges for them. They include Texas and Mississippi, where public officials are campaigning against the health law.

That lack of awareness makes it all the more important that those who do know about HealthCare.gov — and try to purchase insurance there — are not dissuaded because of the glitches, the analysts said. Older and sicker Americans have a stronger incentive to keep trying to sign up despite the clunky site, they said.

Though economists, insurers and health analysts are concerned about the problems with HealthCare.gov, which the Obama administration has promised to fix by Nov. 30, they said it was too early to tell whether the problems would cause an underenrollment of the young and healthy.  Insurers would have a good sense of any problems by next spring, they said. 

No statistics are available on how many of them have signed up. States are providing no demographic details on enrollees. And the Obama administration has declined to say how many people have purchased insurance in the 36 states where it runs the exchanges.

Jonathan Gruber, an economist with the Massachusetts Institute of Technology who helped create the Affordable Care Act, said lessons could be drawn from Massachusetts, which in 2006 implemented a similar law to provide near-universal coverage in the state.

Many Massachusetts residents waited until just before the state law's tax penalty kicked in before signing up for insurance, he said. Just 123 people signed up for subsidized insurance in the first month of enrollment, and only about 2,000 in the second month.

Ms. Collins, of the Commonwealth Fund, also said the federal requirement to buy insurance might compel the young and healthy to sign up. "As people learn about the provisions, and become aware of them, enrollment increases," she said. "It may be that healthy people procrastinate longer than unhealthy people."

Gary Claxton, a policy expert with the Kaiser Family Foundation, noted that provisions in the law help ease the costs to insurers if the enrollment mix raises medical costs more than expected, so they might not increase premiums too sharply.

"If insurers are convinced the people that they've enrolled are going to continue to be sicker than expected, premiums will go up," he said. "But if they believe people who didn't enroll in the first year will show up in the second, it might not have that big an impact on premiums."

For now, the Obama administration is rushing to make signing up as smooth as possible to ensure that the young and healthy enroll. Mr. Jackson, of Ohio, intends to see his application through.

"At this point, I'm just printing it out and sending it in," he said, referring to one of the offline options for signing up. "I'll probably have it done by the end of the month."

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Well: Children, Too, Need Flu Shots

Seasonal flu killed 830 children from 2004 to 2012, and 43 percent of them had no high-risk medical conditions. The rest of the children had neurological, pulmonary, cardiac and other serious disorders.

A new report, published in Pediatrics, used data from the Centers for Disease Control and Prevention on laboratory-confirmed cases of influenza in children under 18.

Recommendations for vaccination changed over the period, but since 2008, the C.D.C. has recommended a flu shot for everyone 6 months or older.

Of the 511 children whose vaccination status was known, 84 percent had not had a flu shot. In the 2009-10 flu season, when 66 children with a known vaccination status died, 64 of them were unvaccinated.

Death often came quickly: most of the children died within a week of the appearance of symptoms, and a third of them died outside the hospital or in an emergency room.

"A lot of parents don't think of flu as being very serious, especially if their child is healthy" said the lead author, Dr. Karen K. Wong, a medical officer with the C.D.C. "But this study shows that even healthy children are at risk, and that's why it's important for every child to get vaccinated."

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Well: Commuting’s Hidden Cost

My twin grandsons, now 13, walk nearly a mile to and from school and play basketball in the schoolyard for an hour or more most afternoons, when weather and music lessons permit.

The boys, like their father, are lean, strong and healthy. Their parents chose to live in New York, where their legs and public transit enable them to go from place to place efficiently, at low cost and with little stress (usually). They own a car but use it almost exclusively for vacations.

"Green" commuting is a priority in my family. I use a bicycle for most shopping and errands in the neighborhood, and I just bought my grandsons new bicycles for their trips to and from soccer games, accompanied by their cycling father.

My son used to work in New Jersey, which entailed a hated commute by car that took 50 to 90 minutes each way. He quit that job when his sons were born and, working part-time from home, cared for the boys. He now commutes to work in the city by foot and by subway, giving him time to read for pleasure.

As you'll soon see, the change has probably been good for his health, too.

According to the Census Bureau, more than three-fourths of all commuters drove to work in single-occupancy vehicles in 2009. Only 5 percent used public transportation, and 2.9 percent walked to work. A mere 0.6 percent rode bicycles, although cycling has finally begun to rise in popularity as cities like New York create bike lanes and bike share programs.

But workers are not the only ones driving for hours a day. The mid-20th century suburban idyll of children going out to play with friends in backyards and on safe streets has yielded to a new reality: play dates, lessons and organized activities to which they must be driven and watched over by adults.

In "My Car Knows the Way to Gymnastics," an aptly titled chapter in Leigh Gallagher's prophetic new book, "The End of the Suburbs," she describes a stay-at-home mom in Massachusetts who drives more than her commuting husband — 40 to 50 miles each weekday, "just to get herself and her children around each day."

Millions of Americans like her pay dearly for their dependence on automobiles, losing hours a day that would be better spent exercising, socializing with family and friends, preparing home-cooked meals or simply getting enough sleep. The resulting costs to both physical and mental health are hardly trivial.

Suburban sprawl "has taken a huge toll on our health," wrote Ms. Gallagher, an editor at Fortune magazine. "Research has been piling up that establishes a link between the spread of sprawl and the rise of obesity in our country. Researchers have also found that people get less exercise as the distances among where we live, work, shop and socialize increase.

"In places where people walk more, obesity rates are much lower," she noted. "New Yorkers, perhaps the ultimate walkers, weigh six or seven pounds less on average than suburban Americans."

A recent study of 4,297 Texans compared their health with the distances they commuted to and from work.It showed that as these distances increased, physical activity and cardiovascular fitness dropped, and blood pressure, body weight, waist circumference and metabolic risks rose.

The report, published last year in The American Journal of Preventive Medicine by Christine M. Hoehner and colleagues from the Washington University School of Medicine in St. Louis and the Cooper Institute in Dallas, provided causal evidence for earlier findings that linked the time spent driving to an increased risk of cardiovascular death. The study examined the effects of a lengthy commute on health over the course of seven years. It revealed that driving more than 10 miles one way, to and from work, five days a week was associated with an increased risk of developing high blood sugar and high cholesterol. The researchers also linked long driving commutes to a greater risk of depression, anxiety and social isolation, all of which can impair the quality and length of life

A Swedish study has confirmed the international reach of these effects. Erika Sandow, a social geographer at Umea University, found that people who commuted more than 30 miles a day were more likely to have high blood pressure, stress and heart disease. In a second study, Dr. Sandow found that women who lived more than 31 miles from work tended to die sooner than those who lived closer to their jobs. Regardless of how one gets to work, having a job far from home can undermine health. Another Swedish study, directed by Erik Hansson of Lund University, surveyed more than 21,000 people ages 18 to 65 and found that the longer they commuted by car, subway or bus, the more health complaints they had. Lengthy commutes were associated with greater degrees of exhaustion, stress, lack of sleep and days missed from work.

Back in the United States, a study of those who commute to work via the Long Island Rail Road linked long commutes with fewer hours of sleep and greater daytime sleepiness.

In her book, Ms. Gallaher happily recounts some important countervailing trends: more young families are electing to live in cities; fewer 17-year-olds are getting driver's licenses; people are driving fewer miles; and bike sharing is on the rise. More homes and communities are being planned or reconfigured to shorten commutes, reduce car dependence and facilitate positive interactions with other people.

Dr. Richard Jackson, the chair of environmental health sciences at the University of California, Los Angeles, says demographic shifts are fueling an interest in livable cities. Members of Generation Y tend to prefer mixed-use, walkable neighborhoods and short commutes, he said, and childless couples and baby boomers who no longer drive often favor urban settings.

While there is still a long way to go before the majority of Americans live in communities that foster good health, more urban planners are now doing health-impact assessments and working closely with architects, with the aim of designing healthier communities less dependent on motorized

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Vocations: For a Traveling Nurse, Freedom to Roam

Anne McQuary for The New York Times

Monica Parks has had contracts that run from six or eight to 13 weeks, and they've often been renewed.

Monica Parks, 43, of Easley, S.C., has been working as a traveling nurse since 2007.

Q. Why did you decide to do this for a living?

A. Traveling nurses work in different locations for weeks at a time. I like the flexibility of being able to pick where I work and take jobs when I want. This work pays well. I get to work in different environments, and I'm not involved in the politics you might find in a staff job.

How do you get assignments, and what about living arrangements?

There are agencies that cater to nurses and doctors who want to travel around the country for work. I've had contracts that run from six or eight to 13 weeks, and they've often been renewed. Traveling nurses are often needed to fill in for people who are out. A hospital will either offer lodging or pay a lodging stipend so we can find our own housing.

Doesn't it get lonely working away from home?

Not at all. I make friends wherever I go. I'm working in South Carolina now, so I'm close to home. But this summer I worked in Washington, D.C. There's so much to do there, and I got together with colleagues all the time. One was from the South, like me, and had several of us over for a Lowcountry boil — corn, potatoes, shrimp, sausage and crab legs.

What did you do before?

I was a staff nurse in the trauma unit of a South Carolina hospital for 14 years. I felt like I saw just about everything there is to see. After that experience, I'm confident I can work in a lot of areas, but my specialties are the operating room and gastroenterology. I'm given some pretty responsible jobs. I was also at the D.C. hospital before this last assignment there, so they knew me. This summer, a nurse manager going on medical leave asked me to train three nurses on nursing fellowships.

But aren't you away from your family for several weeks at a time?

That's the beauty of this type of work: I look for contracts at hospitals and outpatient centers that aren't too far from home. This summer, my husband and our two children, 16 and 12, stayed with me in my D.C. apartment. My husband works from home, so he was able to work when he was there. When the kids started school, I drove to South Carolina every other weekend. I do the same thing as anyone else whose job takes them out of town, or who lives in one city but works in another.

Vocations asks people about their jobs. Interview conducted and condensed by Patricia R. Olsen.

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Applied Science: Maybe Heaven Can Wait, but a Customer Can’t

"Patience is a virtue," we are taught. And when you think about it, much of our life is spent waiting for something rather than experiencing it, so that waiting becomes an experience in itself, filled with anticipation, annoyance, boredom or fear.

Waiting is a ripe subject for business researchers, it turns out. One effect of waiting is that people place more value on what they are waiting for, says Ayelet Fishbach, a professor of behavioral science and marketing at the University of Chicago. "If you give people exactly what they want at the moment they want it, they might want it less," she says.

In one study she helped conduct, two groups of people were given a choice between waiting six days to get a box of Godiva chocolates and waiting 48 days for a bigger box. One group was asked questions meant to accentuate the idea of waiting, like "When was the last time you ate a Godiva chocolate?" Those who were primed to be more conscious of waiting were more likely to delay gratification and choose the bigger box.

If companies can find ways to artificially introduce waiting into the buying process — building excitement without giving the impression of bad service — customers may spend more, Professor Fishbach says. Apple is a master at this, she says, providing details of models before products are available.

Of course, many companies unintentionally do the opposite: they antagonize customers seeking help by forcing them to wait — whether in physical lines, on the phone or online. This leads to ill will and lost sales across many industries.

One researcher has studied this phenomenon in an area that can mean the difference between life and death: hospital emergency rooms.

Hospitals keep track of a category of patient known as "left without being seen," a high number of which is a bad sign. To help keep that number low, Christian Terwiesch, a professor of operations and information management at the Wharton School of the University of Pennsylvania, studied how emergency rooms might improve their admissions processes.

In E.R.'s, people are seen based on the severity of their medical condition. If you are otherwise going to die in the next half-hour, you get to jump to the front of the line. But fellow patients may not realize this, and seeing someone who only just arrived go first can upset people's sense of fairness. Some may leave the waiting room because they feel cheated, Professor Terwiesch says.

Typically, hospitals don't tell patients how long they may have to wait, and patients waiting in the E.R. have no idea when they will be called: "Every time the door opens, your adrenaline goes up."

He found that people in E.R.'s are constantly seeking visual clues as to who might be treated next. But these clues can mislead. At peak hours, an E.R. at full capacity may be able to handle 10 people quickly, yet it may not initially look that way to the 10th person in the waiting room.

Professor Terwiesch recommends that hospitals create multiple waiting rooms so that patients don't try to monitor one another this way. He also says that more hospitals should share waiting-time estimates with patients — something that is relevant across a broad range of industries: if customers know the probable wait time, their uncertainty and anxiety are reduced, along with the likelihood that they will leave the line.

Or, if they are on a call-center phone line and the automated voice says the wait will be 45 minutes, they may choose to hang up and do something better with their time. After all, so long as you're not on the brink of death in the E.R., deciding to stop waiting can be a virtue all its own.

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The E-Cigarette Industry, Waiting to Exhale

Fred R. Conrad/The New York Times

An NJOY e-cigarette. A pioneer in its industry, NJOY now has 200 rivals, including major tobacco companies.

Geoff Vuleta was in the crowd at a Rolling Stones concert last year when Keith Richards lit up a cigarette on stage, the arena's no-smoking policy be damned. Feeling inspired, Mr. Vuleta, a longtime smoker, reached into his pocket and pulled one out himself. People seated nearby shot him scolding glances as he inhaled. So he withdrew the cigarette from his mouth and pressed the glowing end to his cheek.

Joshua Lott for The New York Times

"We have to narrow as much as possible the bridge to familiarity," Craig Weiss, NJOY's president, said of the selling of e-cigarettes. "We have to make it easy for smokers to cross it."

His was an electronic cigarette, a look-alike that delivers nicotine without combusting tobacco and produces a vapor, not smoke. Mr. Vuleta, 51, who has a sardonic humor, clearly relished recounting this story. He is the chief marketing officer for NJOY, an electronic cigarette company based in Scottsdale, Ariz., and it is his job to reframe how everyone, nonsmokers included, view the habit of inhaling from a thin stick and blowing out a visible cloud.

Mr. Vuleta, who told his tale in the office of Craig Weiss, the NJOY chief executive, calls this a process of "renormalizing," so that smokers can come back in from the cold. He means that literally — allowing people now exiled to the sidewalks back into buildings with e-cigarettes. But he also means it metaphorically. Early in the last century, smoking was an accepted alternative for men to chewing tobacco; for women, it was daring and transgressive. Then, in midcentury, it became the norm. As the dangers of tobacco — and the scandalous behavior of tobacco companies in concealing those dangers — became impossible to ignore, smoking took on a new identity: societal evil.

Mr. Vuleta and Mr. Weiss want to make "vaping," as e-cigarette smoking is known in the industry, acceptable. Keith Richards might still be smoking tobacco, but in Mr. Vuleta's vision, that grizzled guitarist's gesture could inspire the audience, en masse, to pull out e-cigarettes. "The moment Keith Richards does it," he said, "everyone else does, too."

Mr. Vuleta's words are more exuberant than the official company line, which is that NJOY doesn't want everyone to smoke e-cigarettes but only to convert the 40 million Americans who now smoke tobacco. The customers NJOY attracts, and how it attracts them, are at the center of a new public health debate, not to mention a rush to control the e-cigarette business.

At stake is a vaping market that has grown in a few short years to around $1.7 billion in sales in the United States. That is tiny when compared to the nation's $90 billion cigarette market. But one particularly bullish Wall Street analyst projects that consumption of e-cigarettes will outstrip regular ones in the next decade.

NJOY was one of the first companies to sell e-cigarettes; now there are 200 in the United States, most of them small. Just last year, however, Big Tobacco got into the game when Lorillard acquired Blu, an e-cigarette brand, and demonstrated its economic power. Within months, relying on Lorillard's decades-old distribution channels, Blu displaced NJOY as the market leader.

Mr. Weiss still sees NJOY as having an advantage — in building e-cigarettes that look, feel and perform like the real thing. It's a different strategy than that of competing products that look like long silver tubes or sleek, blinking fountain pens.

"We're trying to do something very challenging: change a habit that is not only entrenched but one people are willing to take to their grave," said Mr. Weiss, who is not a smoker but has tried both regular and e-cigarettes. "To accomplish that, we have to narrow as much as possible the bridge to familiarity. We have to make it easy for smokers to cross it."

To some, though not all, in public health, that vision sounds ill-conceived, if not threatening. Among their concerns is that making smoking-like behavior O.K. again will undo decades of work demonizing smoking itself. Far from leading to more smoking cessation, they argue, e-cigarettes will ultimately revive it, and abet new cases of emphysema, heart disease and lung cancer.

"The very thing that could make them effective is also their greatest danger," said Dr. Tim McAfee, director of Office on Smoking and Health at the Centers for Disease Control and Prevention.

To achieve his ends, Mr. Weiss is building a company of strange bedfellows. He has hired former top tobacco industry executives, but also attracted a former surgeon general, Dr. Richard H. Carmona, who has joined the board. NJOY recently hired away a prominent professor of chemistry and genomics from Princeton to be the company's chief scientist. The company has attracted investment from Sean Parker, the former Facebook president, and Peter Thiel, the PayPal co-founder. There has also been a celebrity endorsement from the singer Bruno Mars.

Mr. Weiss sees his company as doing something epic. Not long after he was named its president in June 2010, he asked his psychologist if he might record his regular sessions. It was an unusual request, but he thinks that recording his thoughts might ultimately help him write a book or movie script about how he and the company made the cigarette obsolete.

"We're at this incredible inflection point in history," he said, adding that the company has a chance to "make the single most beneficial impact on society in this century."

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Few Problems With Cannabis for California

LOS ANGELES — In the heart of Northern California's marijuana growing region, the sheriff's office is inundated each fall with complaints about the stench of marijuana plots or the latest expropriation of public land by growers. Its tranquil communities have been altered by the emergence of a wealthy class of marijuana entrepreneurs, while nearly 500 miles away in Los Angeles, officials have struggled to regulate an explosion of medical marijuana shops.

But at a time when polls show widening public support for legalization — recreational marijuana is about to become legal in Colorado and Washington, and voter initiatives are in the pipeline in at least three other states — California's 17-year experience as the first state to legalize medical marijuana offers surprising lessons, experts say.

Warnings voiced against partial legalization — of civic disorder, increased lawlessness and a drastic rise in other drug use — have proved unfounded.

Instead, research suggests both that marijuana has become an alcohol substitute for younger people here and in other states that have legalized medical marijuana, and that while driving under the influence of any intoxicant is dangerous, driving after smoking marijuana is less dangerous than after drinking alcohol.

Although marijuana is legal here only for medical use, it is widely available. There is no evidence that its use by teenagers has risen since the 1996 legalization, though it is an open question whether outright legalization would make the drug that much easier for young people to get, and thus contribute to increased use.

And though Los Angeles has struggled to regulate marijuana dispensaries, with neighborhoods upset at their sheer number, the threat of unsavory street traffic and the stigma of marijuana shops on the corner, communities that imposed early and strict regulations on their operations have not experienced such disruption.

Imposing a local tax on medical marijuana, as Oakland, San Jose and other communities have done, has not pushed consumers to drug dealers as some analysts expected. Presumably that is because it is so easy to get reliable and high-quality marijuana legally.

Finally, for consumers, the era of legalized medical marijuana has meant an expanded market and often cheaper prices. Buyers here gaze over showcases offering a rich assortment of marijuana, promising different potencies and different kinds of highs. Cannabis sativa produces a pronounced psychological high, a "head buzz," while cannabis indica delivers a more relaxed, lethargic effect, a "body buzz."

Advocates for marijuana legalization see the moves in Colorado and Washington as the start of a wave. A Gallup poll released last week found that 58 percent of Americans think the drug should be made legal.

"There is definitely going to be a legalization here at some point, one way or another, like in Colorado and Washington," said Tom Ammiano, a Democratic state assemblyman from San Francisco who has pushed the Legislature to legalize recreational marijuana use.

Still, even as public opinion in support of legalizing marijuana has grown, opposition remains strong among many, including some law enforcement organizations, which warn that the use of the drug leads to marijuana dependence, endangers the health of users and encourages the use of other drugs.

"Unfortunately, many have been convinced that marijuana is harmless, and many in policing do not believe that is the case," Darrel W. Stephens, the executive director of the Major Cities Chiefs Association, wrote in an e-mail.

Craig T. Steckler, a former chief of the Police Department in Fremont, Calif., who is now the president of the International Association of Chiefs of Police, said the problems in Los Angeles and robberies of cash-rich marijuana farms in Northern California were just two of the reasons states should hesitate before legalizing the drug.

"If it's more readily accessible, if the parents and the siblings are doing it, then it becomes available to the younger kids — it's going to be in the house, it's going to be in the car," he said.

"Where does it stop?" Mr. Steckler asked. "You make all drugs legal? Or just marijuana for now and suffer for that? What happens when you find out this wasn't such a good idea?"

After California, medical marijuana was legalized in 19 states and the District of Columbia, according to the National Conference of State Legislatures.

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