Insurers Claim Health Website Is Still Flawed

Weeks of frantic technical work appear to have made the government's health care website easier for consumers to use. But that does not mean everyone who signs up for insurance can enroll in a health plan.

The problem is that so-called back end systems, which are supposed to deliver consumer information to insurers, still have not been fixed. And with coverage for many people scheduled to begin in just 30 days, insurers are worried the repairs may not be completed in time.

"Until the enrollment process is working from end to end, many consumers will not be able to enroll in coverage," said Karen M. Ignagni, president of America's Health Insurance Plans, a trade group.

The issues are vexing and complex. Some insurers say they have been deluged with phone calls from people who believe they have signed up for a particular health plan, only to find that the company has no record of the enrollment. Others say information they received about new enrollees was inaccurate or incomplete, so they had to track down additional data — a laborious task that would not be feasible if data is missing for tens of thousands of consumers.

In still other cases, insurers said, they have not been told how much of a customer's premium will be subsidized by the government, so they do not know how much to charge the policyholder.

In trying to fix HealthCare.gov, President Obama has given top priority to the needs of consumers, assuming that arrangements with insurers could be worked out later.

The White House announced on Sunday that it had met its goal for improving HealthCare.gov so the website "will work smoothly for the vast majority of users."

In effect, the administration gave itself a passing grade. Because of hundreds of software fixes and hardware upgrades in the last month, it said, the website — the main channel for people to buy insurance under the 2010 health care law — is now working more than 90 percent of the time, up from 40 percent during some weeks in October.

Jeffrey D. Zients, the presidential adviser leading the repair effort, said he had shaken up management of the website so the team was now "working with the velocity and discipline of a high-performing private sector company."

Mr. Zients said 50,000 people could use the website at the same time and that the error rate, reflecting the failure of web pages to load properly, was consistently less than 1 percent, down from 6 percent before the overhaul.

Pages on the site generally load faster, in less than a second, compared with an average of eight seconds in late October, Mr. Zients said.

Whether Mr. Obama can fix his job approval ratings as well as the website is unclear. Public opinion polls suggest he may have done more political damage to himself in the last two months than Republican attacks on the health care law did in three years.

People who have tried to use the website in the last few days report a mixed experience, with some definitely noticing improvements.

"Every week, it's been getting better," said Lynne M. Thorp, who leads a team of counselors, or navigators, in southwestern Florida. "It's getting faster, and nobody's getting kicked out."

But neither Mr. Zients nor the Department of Health and Human Services indicated how many people were completing all the steps required to enroll in a health plan through the federal site, which serves residents of 36 states.

And unless enrollments are completed correctly, coverage may be in doubt.

For insurers the process is maddeningly inconsistent. Some people clearly are being enrolled. But insurers say they are still getting duplicate files and, more worrisome, sometimes not receiving information on every enrollment taking place.

"Health plans can't process enrollments they don't receive," said Robert Zirkelbach, a spokesman for America's Health Insurance Plans.

Despite talk from time to time of finding some sort of workaround, experts say insurers have little choice but to wait for the government to fix these problems. The insurers are in "an unenviable position," said Brett Graham, a managing director at Leavitt Partners, which has been advising states and others on the exchanges. "Although they don't have the responsibility or the capability to fix the system, they're reliant on it."

Jess Bidgood, Dan Frosch and Jennifer Preston contributed reporting.

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Op-Ed Contributor: Bad Eating Habits Start in the Womb

THE solution to one of America's most vexing problems — our soaring rates of obesity and diet-related diseases — may have its roots in early childhood, and even in utero.

Researchers at the Monell Chemical Senses Center, a nonprofit research organization in Philadelphia, have found that babies born to mothers who eat a diverse and varied diet while pregnant and breast-feeding are more open to a wide range of flavors. They've also found that babies who follow that diet after weaning carry those preferences into childhood and adulthood. Researchers believe that the taste preferences that develop at crucial periods in infancy have lasting effects for life. In fact, changing food preferences beyond toddlerhood appears to be extremely difficult.

"What's really interesting about children is, the preferences they form during the first years of life actually predict what they'll eat later," said Julie Mennella, a biopsychologist and researcher at the Monell Center. "Dietary patterns track from early to later childhood but once they are formed, once they get older, it's really difficult to change — witness how hard it is to change the adult. You can, but it's just harder. Where you start, is where you end up."

This may have profound implications for the future health of Americans. With some 70 percent of the United States population now overweight or obese and chronic diseases skyrocketing, many parents who are eating a diet high in processed, refined foods are feeding their babies as they feed themselves, and could be setting their children up for a lifetime of preferences for a narrow range of flavors.

The Monell researchers have identified several sensitive periods for taste preference development. One is before three and a half months of age, which makes what the mother eats while pregnant and breast-feeding so important. "It's our fundamental belief that during evolution, we as humans are exposed to flavors both in utero and via mother's milk that are signals of things that will be in our diets as we grow up and learn about what flavors are acceptable based on those experiences," said Gary Beauchamp, the director of the Monell Center. "Infants exposed to a variety of flavors in infancy are more willing to accept a variety of flavors, including flavors that are associated with various vegetables and so forth and that might lead to a more healthy eating style later on."

There is another reason these exposures have a lifelong impact, he said: "This early exposure leads to an imprinting-like phenomenon such that those flavors are not only preferred but they take on an emotional attachment."

This puts babies fed formula at a disadvantage because the flavors in packaged formula never change. But according to Ms. Mennella, the opportunity to expose those babies to a range of flavors is not lost. "Just because you're formula-fed, it's not hopeless," she said. "Babies learn through repeated exposure, so the more varied the diet, the more likely they'll be to accept a novel food."

Another recent study conducted at the FoodPlus research center at the University of Adelaide in South Australia found that exposure to a maternal junk food diet (defined in the study as any food that was energy dense, highly palatable and had a high fat content) results in children with a preference for these same foods. In a rodent model, the study found that being exposed to too much junk food in utero and through breast milk leads offspring to develop a reward pathway in the brain that is less sensitive than normal. Mothers who were fed foods like Froot Loops, Cheetos and Nutella during pregnancy had offspring that showed increased expression of the gene for an opioid receptor, which resulted in a desensitization to sweet and fatty foods. "The best way to think about how having a desensitized reward pathway would affect you is to use the analogy of somebody who is addicted to drugs," Jessica R. Gugusheff, a Ph.D. candidate at FoodPlus and the lead author of the study, wrote in an email. "When someone is addicted to drugs they become less sensitive to the effects of that drug, so they have to increase the dose to get the same high," she wrote. "In a similar way, by having a desensitized reward pathway, offspring exposed to junk food before birth have to eat more junk food to get the same good feelings."

Ms. Mennella at Monell has also done research on reward pathways for sweetness and has found that sweet flavors have an analgesic effect on babies and children such that babies will cry less and children will leave their hand in a cold water bath for longer periods with sweet flavors in their mouths. Ms. Mennella has also found that in obese children, while the level of sweet they prefer is the same as that of normal-weight children, sweet flavors are not as effective as an analgesic. "I hypothesized maybe it's because of some disruption in the opioid system, so maybe they need more sweet to get the same effect," she said.

These research studies call into question the ethics of marketing poor-quality foods to children as well as the marketing of infant formula.

In the United States, according to the Centers for Disease Control and Prevention, about 15 percent of mothers breast-feed exclusively for six months, with rates significantly lower for African-American mothers. The American Academy of Pediatrics recommends that women breast-feed exclusively for at least six months and then continue some breast-feeding as they introduce solid foods for the next six months. The World Health Organization recommends breast-feeding up to 2 years of age or beyond.

But infant formula is a booming billion-dollar industry with three companies controlling almost 98 percent of the market: Mead Johnson, maker of Enfamil, Abbott, manufacturer of Similac, and Nestlé (now Gerber), maker of Good Start.

Functional foods, or foods that allegedly deliver nutritional benefit beyond what is available in natural foods, are a food industry creation to convince consumers that their products are superior to, or can replace, natural, whole foods. Globally, infant formula is the fastest growing functional food; the market is on track to grow by nearly $5 billion in 2013 alone.

But formula is only part of the problem since breast-fed babies of mothers eating too many refined and processed foods are also at risk. Claims by the food industry that personal responsibility, exercising more, and eating less are the solutions to obesity and diet-related disease are turned on their head with these studies. If babies are developing food preferences in utero and before 2 or 3 years of age through no fault of their own, how can we then blame them when they become obese children and adults?

If we hope to reverse the tide on obesity and diet-related disease in America, regulating processed food products and infant formula, and creating clear warning labels to deter parents from feeding their children potentially harmful foods may be our best shot. Let's make sure future generations have the best chance to become healthy adults.

Kristin Wartman, a journalist, is writing a book on how the industrial food system is changing our minds, bodies and culture.

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Urban Schools Aim for Environmental Revolution

Joshua Bright for The New York Times

Kindergartners in Manhattan being served lunch on plates made from sugar cane, which are expected to replace plastic foam trays next year in six districts.

Nothing seemed special about the plates from which students at a handful of Miami schools devoured their meals for a few weeks last spring — round, rigid and colorless, with four compartments for food and a fifth in the center for a carton of milk.

Looks, however, can be deceiving: They were the vanguard of what could become an environmental revolution in schools across the United States.

With any uneaten food, the plates, made from sugar cane, can be thrown away and turned into a product prized by gardeners and farmers everywhere: compost. If all goes as planned, compostable plates will replace plastic foam lunch trays by September not just for the 345,000 students in the Miami-Dade County school system, but also for more than 2.6 million others nationwide.

That would be some 271 million plates a year, replacing enough foam trays to create a stack of plastic several hundred miles tall.

"I want our money and resources for food going into children, not in garbage going to the landfill," said Penny Parham, the Miami school district's administrative director of food and nutrition.

Compostable plates are but the first initiative on the environmental checklist of the Urban School Food Alliance, a pioneering attempt by six big-city school systems to create new markets for sustainable food and lunchroom supplies.

The alliance members — the public school systems in Chicago, Dallas, Los Angeles, Miami, New York and Orlando, Fla. — are betting that by combining their purchasing power, they can persuade suppliers to create and sell healthier and more environment-friendly products at prices no system could negotiate alone.

"We pay about 4 cents for a foam tray, and compostable trays are about 15 cents — but volume is always the game changer," said Leslie Fowler, the director of nutrition support services for the Chicago school system. "We want to set the tone for the marketplace, rather than having the marketplace tell us what's available."

The compostable plates are the first test of the alliance's thesis. This week, the New York City Education Department will open sealed bids to supply the roughly 850,000 plates it needs each day for breakfast and lunch programs in about 1,200 schools. New York is running a pilot program, like Miami's, in four schools, with 30 more expected to join this month.

If a winning bidder is chosen, the other alliance members will be able to piggyback on the contract, placing their own orders without having to navigate a separate bidding process. The call for bids names all six districts and says they must all be allowed to place orders at the same price.

The alliance's next target is healthier food. It is already looking at potential suppliers of antibiotic-free chicken. School officials say possible future initiatives include sustainable tableware, pesticide-free fruit and goods with less packaging waste.

The direct benefits of these efforts may not always be obvious, or even noticeable. To a child, antibiotic-free chicken tastes like any other chicken. And even a huge purchase by the alliance would have little effect on farmers' preferences for giving animals antibiotics, much less on the danger the practice poses: spawning new classes of antibiotic-resistant bacteria.

But short-term environmental and health benefits are not the only goals, said Eric Goldstein, the chief executive of school support services in New York City. Using recyclable plates or serving healthier chicken sets an example that students may carry into adulthood, he said, and that other school systems may come to see as a standard.

"It sounds corny," Mr. Goldstein said, "but we all believe in this."

The six districts banded together in July 2012 at a school-nutrition conference in Denver. They received a lift later last year when the Natural Resources Defense Council, a national advocacy group with a history of pressing governments for environment-friendly changes, met with Mr. Goldstein and other New York school executives to talk about recycling and healthier food.

"We were pleasantly surprised when they told us they were interested both in getting rid of polystyrene trays and moving forward on healthier chicken," said Mark Izeman, the director of the council's New York program.

The council has recruited a law firm to create a nonprofit corporation for the alliance and lent its environmental expertise to help the six districts decide what to buy next. "We're delighted to work with them," Mr. Izeman said. "What's not to like?"

If the alliance succeeds, it could help change nutrition and sustainability policies across the nation. Already, other school districts are asking to join the group. Eventually, Mr. Izeman said, the alliance could be a template for sustainability efforts by other big food bureaucracies. What works for school districts, after all, should also work for institutions like hospitals and universities.

But first, it has to work in public schools. For now, that means producing a compostable plate that school systems can afford.

That may not be easy. Foam trays are made from petroleum byproducts and are stamped out at dizzying rates. Sugar-cane plates take longer to make and require more machinery to produce in volume, said an official at one manufacturer of recycled tableware who did not want to be named because his company is involved in the alliance bid.

Mr. Goldstein said that 21 manufacturers had expressed interest in bidding, and that he believed they would slash prices to win such a huge contract.

But if not, the manufacturing official said, there is a way for alliance members to recoup some of the cost. Demand for compost is high, and by late next year, schools may be deluged with it.

"Budgets are always tough," the official said. "They could sell that mulch, a buck or two a bag."

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Well: Palliative Care, the Treatment That Respects Pain

Anyone faced with a life-threatening or chronic illness should be so lucky as Catherine, a 27-year-old waitress in New York.

Dr. Diane E. Meier, a palliative care specialist at Mount Sinai Medical Center, recalled her young patient's story in an article published in 2011 in the Journal of Clinical Oncology. Catherine, who was not further identified to preserve her privacy, was diagnosed with leukemia and suffered intractable bone pain, unrelieved by acetaminophen with codeine.

Still, she was unwilling to take opioids to relieve the pain because a family member had had problems with substance abuse. Dr. Meier and her team were called in to help, and their counsel allayed the young woman's fears of addiction and helped her understand that pain relief was an important part of her treatment. Catherine recovered, eventually attending graduate school and marrying. Her story, Dr. Meier wrote, told us something about the importance of palliative care: Her doctors were focused on curing her cancer, but it was her suffering that "posed significant — but remediable — burdens on the patient."

Palliative care physicians like Dr. Meier focus on the relief of that suffering, and not just for the dying. All patients deserve palliative care whether they are terminally ill, expected to recover fully, or facing years with debilitating symptoms of a chronic or progressive disease.

"The vast majority of patients who need palliative care are not dying," Dr. Meier, the director of the Center to Advance Palliative Care, said in an interview. "They are debilitated by things like arthritic pain that affect the quality of their lives and ability to function, and can eventually impact their survival."

If I had received palliative care following my double knee replacement, I might have avoided the serious pain that left me depressed and unable to resume a normal life for many more weeks than it should have. If my elderly aunt had access to palliative care when she was placed in intensive care, she might not have become delirious and suffered an abrupt progression of dementia from which she never recovered.

The benefits of palliative care include fewer trips to the emergency room or hospital, lower medical costs, improved ability to function and enjoy life and, several studies have shown, prolonged survival for the terminally ill. These virtues far outweigh what it would cost to make this service universally available in hospitals, nursing homes, clinics, assisted living facilities and patients' homes.

But there are two major stumbling blocks, one of which patients and their families can help to eliminate. First is the widespread misunderstanding of palliative care by the public and the medical profession: Both wrongly equate it with hospice and end-of-life care.

"Hospice is a form of palliative care for people who are dying, but palliative care is not about dying," Dr. Meier said. "It's about living as well as you can for as long as you can."

A 2011 survey of 800 adults, commissioned by the center, found that 70 percent were "not at all knowledgeable" about palliative care. But once informed, a similar percentage believed that it was "very important for patients with serious illness to have access to palliative care at all hospitals," and that such care was appropriate at any age and any stage of a serious illness.

The second obstacle to making palliative care more available is a shortage of doctors trained in it. It was first declared a medical specialty in 2007, but even today few medical students and residents receive instruction in this field despite its importance to the quality and cost of medical care.

Other specialists too seldom request this service for patients who need it, researchers say. Many still believe palliative care is appropriate only when nothing more can be done to treat a patient's disease and prolong life. But unlike hospice, palliative care can and should be delivered while patients continue treatment for their diseases.

"Most doctors in practice today were trained more than 20 years ago, when palliative care didn't exist," Dr. Meier noted.

Under the Affordable Care Act, hospitals now face huge penalties when Medicare patients are repeatedly readmitted for chronic or recurrent conditions. This is expected to boost the use of palliative care, which has been shown to reduce patients' dependence on emergency rooms and need for hospitalization. Palliative care is also available in a growing number of children's hospitals.

Among older people, 90 percent of visits to emergency rooms are for distressing symptoms like pain, shortness of breath and fatigue that can accompany chronic illness, Dr. Meier said. "These symptoms can and should be prevented or managed by palliative care specialists in a patient's own home," she said. "Patients turn to hospitals for care because they have no alternative."

Palliative care is not limited to direct medical care. It includes help in accessing community services, obtaining affordable health care and living assistance at home, ensuring a safe environment in the home, and determining what is most important to a patient's quality of life and how those goals might be achieved.

A typical palliative care team includes doctors, nurses and a social worker to help patients and their families navigate complex needs both in a medical setting and at home. The goal, whenever possible, is to help patients live in their own residences for as long as possible and enjoy a reasonable quality of life.

Dr. Meier urges patients and families to check whether there is a palliative care team at the hospital they would normally use. If not, go to a hospital that has one and let the first hospital know why. Check the website www.getpalliativecare.org for nearby hospitals with a palliative care team.

Most American hospitals with more than 50 beds offer palliative care, but often "patients and families must be proactive to get the services they need," Dr. Meier said. "They should take the initiative to get needed help and say they have to be seen by a palliative care specialist."

Palliative care services in both medical settings and patients' homes are covered by private insurance, Medicare and Medicaid, depending on the patient's reason for seeing a doctor.

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Inside the Race to Rescue a Health Care Site, and Obama

WASHINGTON — As a small coterie of grim-faced advisers shuffled into the Oval Office on the evening of Oct. 15, President Obama's chief domestic accomplishment was falling apart 24 miles away, at a bustling high-tech data center in suburban Virginia.

The Times would like to hear from Americans who have begun to sign up for health care under the Affordable Care Act.

HealthCare.gov, the $630 million online insurance marketplace, was a disaster after it went live on Oct. 1, with a roster of engineering repairs that would eventually swell to more than 600 items. The private contractors who built it were pointing fingers at one another. And inside the White House, after initially saying too much traffic was to blame, Mr. Obama's closest confidants had few good answers.

The political dangers were clear to everyone in the room: Vice President Joseph R. Biden Jr.; Kathleen Sebelius, the health secretary; Marilyn Tavenner, the Medicare chief; Denis McDonough, the chief of staff; Todd Park, the chief technology officer; and others. For 90 excruciating minutes, a furious and frustrated president peppered his team with questions, drilling into the arcane minutiae of web design as he struggled to understand the scope of a crisis that suddenly threatened his presidency.

"We created this problem we didn't need to create," Mr. Obama said, according to one adviser who, like several interviewed, insisted on anonymity to share details of the private session. "And it's of our own doing, and it's our most important initiative."

Out of that tense Oval Office meeting grew a frantic effort aimed at rescuing not only the insurance portal and Mr. Obama's credibility, but also the Democratic philosophy that an activist government can solve big, complex social problems. Today, that rescue effort is far from complete.

The website, which the administration promised would "function smoothly" for most people by Nov. 30, remains a work in progress. It is more stable, with many more people able to use it simultaneously than just two weeks ago. But it still suffers sporadic crashes, and large parts of the vital "back end" that processes enrollment data and transactions with insurers remain unbuilt. The president, who polls showed was now viewed by a majority of Americans as not trustworthy, has conceded that he needs to "win back" his credibility.

Another round of hardware upgrades and software fixes was planned for Saturday night. Administration officials say they will give a public update about the site's performance on Sunday morning.

The story of how the administration confronted one of the most perilous moments in Mr. Obama's presidency — drawn from documents and from interviews with dozens of administration officials, lawmakers, insurance executives and tech experts working inside the HealthCare.gov "war room" — reveals an insular White House that did not initially appreciate the magnitude of its self-inflicted wounds, and sought help from trusted insiders as it scrambled to protect Mr. Obama's image.

After a month of bad publicity and intensifying Republican attacks, the sense of crisis and damage control inside the White House peaked on Oct. 30, as the president's top aides began to fully grasp the breadth of the political challenges they faced. As Ms. Sebelius was grilled by Congressional Republicans that day, Mr. Obama flew to Boston to defend the health law and confront a new accusation: that he had lied about whether people could keep their insurance. Meanwhile, Mr. McDonough huddled at the Democratic National Committee headquarters with a small group of freshman House members whose anxiety was soaring.

The day was a brutal reminder for top White House advisers that fixing the botched health care rollout would be critical to restoring their boss's agenda and legacy. To do that, they would have to take charge of a project that, they would come to discover, had never been fully tested and was flailing in part because of the Medicare agency's decision not to hire a "systems integrator" that could coordinate its complex parts. The White House would also have to hold together a fragile alliance of Democratic lawmakers and insurance executives.

"If we don't do that," one senior White House adviser recalled, "it's a very serious threat to the success of the legislation and a very serious threat to him. We get that."

The urgent race to fix the website — now playing out behind the locked glass doors of the closely guarded war room in Columbia, Md. — has exposed a deeply dysfunctional relationship between the Department of Health and Human Services and its technology contractors, and tensions between the White House chief of staff and senior health department officials. It strained relations between the Obama administration and the insurance industry, helped revive a Republican Party battered after the two-week government shutdown and frustrated, even infuriated, Congressional Democrats.

But as the president's team gathered on Oct. 15 — with a budget deal finally in sight on Capitol Hill — his difficulties were only just becoming clear to the White House. As aides left the Oval Office that evening, clutching notes filled with what Mr. McDonough called "do-outs," or assignments, political pressure was mounting.

Reporting was contributed by Reed Abelson and Sharon LaFraniere from New York, Ian Austen from Ottawa, and Robert Pear from Washington.

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Abortion Cases in Court Helped Tilt Democrats Against the Filibuster

J. Scott Applewhite/Associated Press

"This constituted an attack on the balance and integrity of our courts," said Senator Jeff Merkley, a leading proponent of restricting the use of the filibuster.

"These are the kinds of decisions we are going to have to live with," a blunt Senator Harry Reid, the Democratic majority leader, warned his caucus later as it weighed whether to make historic changes to Senate rules. Those changes would break a Republican filibuster of President Obama's nominees and end the minority party's ability to block a president's choices to executive branch posts and federal courts except the Supreme Court.

The moment represented a turning point in what had been, until then, a cautious approach by Democrats to push back against Republicans who were preventing the White House from appointing liberal judges. All the more glaring, Democrats believed, was that they had allowed confirmation of the conservative judges now ruling in the abortion cases. Republicans were blocking any more appointments to the court of appeals in Washington, which issued the contraception decision.

Faced with the possibility that they might never be able to seat judges that they hoped would act as a counterweight to more conservative appointees confirmed when George W. Bush was president, all but three of the 55 members of the Senate Democratic caucus sided with Mr. Reid. The decision represented a recognition by Democrats that they had to risk a backlash in the Senate to head off what they saw as a far greater long-term threat to their priorities in the form of a judiciary tilted to the right.

"The final tipping point was this month, when the minority launched a campaign to block President Obama from appointing anyone, regardless of experience and character, to three vacancies on the D.C. circuit court," said Senator Jeff Merkley, Democrat of Oregon and one of the leading proponents of filibuster limits. "This constituted an attack on the balance and integrity of our courts."

The question of the composition of the federal judiciary has become even more pressing for liberals, given the battery of abortion rights cases now making their way through the courts. From Texas to South Dakota to Wisconsin, federal courts across the country — many of them with vacancies that the president will now be able to fill — are seeing their dockets grow with challenges to restrictive new anti-abortion laws.

Very quickly and unexpectedly, abortion and contraceptive rights became the decisive factor in the filibuster fight. First there were the two coincidentally timed decisions out of Texas and Washington. Then momentum to change the rules reached a critical mass when Senator Barbara Boxer, Democrat of California and a defender of abortion rights, decided to put aside her misgivings, in large part because the recent court action was so alarming to her, Democrats said.

Mr. Reid and many members of his caucus found it especially disquieting that in 2005 they agreed to confirm the two judges who wrote the recent decisions — Janice Rogers Brown of the United States Court of Appeals for the District of Columbia Circuit and Priscilla R. Owen of the United States Court of Appeals for the Fifth Circuit — as part of a deal with Senate Republicans, who controlled the chamber at the time and were threatening to limit Democrats' ability to filibuster judges if some of Mr. Bush's nominees were not approved.

Conservatives have always viewed the federal courts as a last line of defense in the country's cultural and political fights. Among their base it is a central tenet that electing Republican presidents is vital precisely because they appoint right-leaning judges who will keep perceived liberal overreach in check.

The issue has never been as powerful for liberals. Consider, for example, how often Republican candidates laud Supreme Court justices like Antonin Scalia and Clarence Thomas compared with how relatively rarely Democrats mention liberal justices like Ruth Bader Ginsburg.

"Republicans and conservatives have been better about the base understanding the significance of judicial nominations than the groups left of center," said Jay Sekulow, chief counsel of the American Center for Law and Justice, which fights for conservative causes in the courts.

Partly for that reason, conservatives say Republicans will not be afraid to force their preferred judges through the Senate should it and the White House flip back to Republican control. "There was this rule in place, and it'd been in place for a long time to prevent the kind of thing you're going to see now, which is attempted court packing," Mr. Sekulow said. "Republicans won't be afraid to return the favor."

In the case before the Washington appeals court, Judge Brown issued an opinion siding with Freshway Foods, a produce company that opposes contraception and abortion so strongly that some of its delivery trucks have been emblazoned with signs declaring, "It's not a choice, it's a child." In the opinion, she likened the government's requirement that the company cover birth control for its employees to affirming "a repugnant belief" and wrote that the company would be forced to be "complicit in a grave moral wrong."

In the Texas case, which is still in its early stages and set to be argued in January, Judge Owen agreed that the state had a legitimate public health reason for requiring that doctors who perform abortions have admitting privileges at nearby hospitals and rejected the claim by Planned Parenthood of Greater Texas and other plaintiffs that the state was placing too high a burden on women who want the procedure. Because many abortion doctors do not have admitting privileges, clinics across the state have shut down since the court's ruling.

A case challenging a similar law in Wisconsin will go before the federal appeals circuit court in Chicago next week, and other cases challenge admitting privileges laws in Mississippi and Alabama.

Because these cases continue to move through the courts — and because anti-abortion activists elsewhere are trying to make states like Michigan, Pennsylvania and Georgia the next legal battlegrounds over abortion — Democrats' focus on judges is expected to intensify.

"The courts are critically important backstops for the protection of women's health and the ability of women to access abortion," said Jennifer Dalven, director of the reproductive freedom project at the American Civil Liberties Union, which is fighting legal battles in several states. "But what we saw in Texas reminds us that we cannot be complacent and feel sure that the courts will be there to correct everything. We must stop these laws before they pass."

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Vocations: The Massage Therapist: Healing With His Hands

Chris Hinkle for The New York Times

"It's amazing to see how soothing the touch of a skilled human hand can be," said Manny Granillo, a massage therapist.

Manny Granillo, 59, has been a massage therapist at Miraval Resort and Spa in Tucson for nine years.

Q. How did you choose a career as a massage therapist?

A. It wasn't my first choice. I was born in the copper-mining town of San Manuel, Ariz. Everyone I knew — including my father, uncles and cousins — worked for the Magma Copper mines. I had wanted to go to college, but right after high school I married and was an expectant father at 18, so I went to work for the mines, eventually becoming a pipe fitter. My plan was to retire after 30 years with a nice pension package. That dream ended on June 22, 1999, when the supervisor announced that the mines would close because the price of copper had dropped so much.

Did they offer you an opportunity to work for another mine?

A social worker did suggest I could work for another mine, but I was afraid other mines would close, too. When I told her I wanted to study for a career helping people, perhaps as a massage therapist since I enjoyed working with my hands, she replied that as a Hispanic male I would never get hired at the spas in the Tucson area. But I never gave up. We have an expression in Spanish: Si, se puede — yes, you can.

How did you get the experience to become a massage therapist?

I worked three-day weekends at Miraval as a waiter and attended night classes at massage school. I still needed some kind of job, even though my second wife, Gina, who worked for a juvenile corrections facility, was there to support my dream. I never took a day off and finished a 12-month program in nine months. I'd massage anyone I could lay my hands on — friends, family, babies, dogs! I had a private practice for two years; I went on house calls with my table. With the encouragement of Miraval's then assistant spa director, I got up the nerve to apply to the spa but did not pass their test. I kept practicing, and a year later I passed the test and joined Miraval's spa team.

You sound so passionate about the work you do.

It's amazing to see how soothing the touch of a skilled human hand can be. We go through so much stress in our lives. Much of it we suffer alone, mostly in silence. Our muscles have memory of this stress and trauma and hold onto it a long time. When I see the power I have to relieve and release some of that stress, when I see people cry in gratitude right there on the table, I know I was meant to do this work all along.

Vocations asks people about their jobs. Interview conducted and condensed by Perry Garfinkel.

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Health Care Site Rushing to Make Fixes by Sunday

As the Obama administration's weekend deadline for a smoothly functioning online marketplace for health insurance arrives, more than a month of frantic repair work is paying off with fewer crashes and error messages and speedier loading of pages, according to government officials, groups that help people enroll and experts involved in the project.

But specialists said weeks of additional work lie ahead, including a major reconfiguration of the computer hardware, if the $630 million site, Healthcare.gov, is to accommodate the expected flood of people seeking to buy health insurance. Without the additional changes, experts predict, the website may continue to crash during periods of peak use.

Beyond the prospect of potential delays for consumers, insurers warn that problems remain in the invisible "back end" that transmits enrollment information to them. That data has been plagued by inaccuracies, insurers say. Administration officials have been unwilling to disclose the error rate.

As late as Wednesday, the site still continued to slow down when 30,000 users tried to log on simultaneously, according to project specialists. A batch of hardware upgrades and software fixes scheduled for this weekend, administration officials say, will allow the site to handle 50,000 simultaneous users, as promised, by Dec. 1, which is Sunday.

The Health and Human Services Department announced that the site would be shut down for 11 hours on Friday night to put those upgrades into place, on top of the usual four-hour timeout for maintenance on Saturday night.

Although the administration has postponed a December marketing campaign, fearful that the site would collapse under a surge in traffic, five weeks of repair work have clearly made the exchange better. From last Sunday to Tuesday, nearly 20,000 users managed to enroll in insurance plans, the most for a three-day period, according to people familiar with the project. By comparison, fewer than 27,000 users picked an insurance plan on the federal site in the entire month of October.

And pages that once took an average of eight seconds to load now show up in a fraction of a second. The rate at which a user sees an error message has also dropped from about 6 percent to 0.75 percent.

But the pace of enrollment must pick up drastically if the administration is to meet its target of signing up seven million people by the end of March, the number that insurers say they need to spread risks and keep prices down. While some states that built their own sites are making better progress enrolling people, applicants in 36 states, with two-thirds of the nation's population, depend on the federal site.

At this week's rate of enrollment, those enrolled through the federal exchange would total fewer than 1.1 million by the March deadline. Few insurance executives expect alternative options for enrolling, including by phone, mail, or in person at counseling centers, to make up that gap.

The administration has already spent more than $9 million beefing up the system's computing power with additional servers and other hardware. The reconfiguration of the data center — the website's computer brain — is expected to cost millions more and require up to another month of work, specialists said.

Experts involved in the repair work say the overhaul is necessary because bursts of traffic beyond the designed capacity could bog down the site, forcing users into an electronic queue until emails notify them that they can return.

The only solution, several experts said, is to reconfigure many of the site's computer servers so that they are dedicated solely to HealthCare.gov's tasks. Currently, most of the servers juggle demands from other clients as well.

One expert said the site needs to be able to handle 100,000 simultaneous users to provide a safe margin of error. "Think of it as Version Two," he said.

Tests conducted this week for The New York Times by a California-based company that evaluates websites for major commercial clients found that the site remains too complicated for many users, and is still prone to errors and delays.

Sharon LaFraniere reported from New York, Eric Lipton from Washington, and Ian Austen from Ottawa. Jennifer Preston contributed reporting from New York, and Robert Pear from Washington.

This article has been revised to reflect the following correction:

Correction: November 30, 2013

An earlier version of this article paraphrased incorrectly from comments by Gary L. Bloom, the chief executive of the software vendor MarkLogic. Mr. Bloom said the specifications for a major computer switch that connects the computer servers for HealthCare.gov through a security wall to the Internet had been upgraded to 60 gigabits — not 60 gigabytes — a second from four.

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Paper Tying Rat Cancer to Herbicide Is Retracted

A food safety journal has decided to retract a paper that seemed to show that genetically modified corn and the herbicide Roundup can cause cancer and premature death in rats.

The editor of the journal, Food and Chemical Toxicology, said in a letter to the paper's main author that the study's results, while not incorrect or fraudulent, were "inconclusive, and therefore do not reach the threshold of publication."

The paper, published 14 months ago, has been cited by opponents of biotech foods and proponents of labeling such foods. But it has been vociferously criticized as flawed, sensationalistic and possibly even fraudulent by many scientists, some allied with the biotechnology industry. The main author of the study, Gilles-Eric Séralini, of the University of Caen in France, had done other studies challenging the safety of genetically engineered foods, some of which had also been questioned.

In his letter to Dr. Séralini, A. Wallace Hayes, the editor in chief of the journal, said that "unequivocally" he had found "no evidence of fraud or intentional misrepresentation of the data."

He said that Dr. Séralini had cooperated in providing his raw data to a review panel formed by the journal.

However, Dr. Hayes said there was "legitimate cause for concern" that the number of rats in each arm of the study was too small and that the strain of rat used was prone to cancer. That made it difficult to rule out that the results were not explained by "normal variability," he said.

The letter was posted on the website of GMWatch, a British organization that opposes genetically engineered crops. GMWatch called the journal's action "illicit, unscientific and unethical," saying that inconclusive data was not sufficient grounds for a retraction.

Dr. Hayes, while confirming he wrote the letter, referred questions to an executive at Elsevier, the publisher of the journal.

An email to that executive received an automatic reply saying she was away for Thanksgiving.

The study followed 200 rats for two years, essentially their entire lives. They were divided into 10 groups, each with 10 males and 10 females. Some groups were fed different amounts of a Monsanto corn genetically engineered to resist the herbicide Roundup, also known as glyphosate.

Some of the corn had been sprayed in the field with Roundup and some not. Some other groups were fed different doses of glyphosate in drinking water.

The rats that ate either the corn or the glyphosate tended to have more tumors and die earlier than the 20 rats in the control group, which were fed nonengineered corn and plain water.

The study passed the peer review process of the journal, which is considered one of the leading publications in toxicology. But many letters to the journal then criticized the study, as did food safety authorities in Europe.

Dr. Séralini and some other scientists had defended the paper in letters to the journal. They said the same strain of rats was used by Monsanto in its 90-day feeding study that led to European approval of the corn.

They also said that even though the rats had a high natural rate of cancer, what mattered was the difference in tumor incidence between the rats fed the corn or herbicide and the controls.

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Bits Blog: The Vaccination Effect: 100 Million Cases of Contagious Disease Prevented

Vaccination programs for children have prevented more than 100 million cases of serious contagious disease in the United States since 1924, according to a new study published in The New England Journal of Medicine.

The research, led by scientists at the University of Pittsburgh's graduate school of public health, analyzed public health reports going back to the 19th century. The reports covered 56 diseases, but the article in the journal focused on seven: polio, measles, rubella, mumps, hepatitis A, diphtheria and pertussis, or whooping cough.

Researchers analyzed disease reports before and after the times when vaccines became commercially available. Put simply, the estimates for prevented cases came from the falloff in disease reports after vaccines were licensed and widely available. The researchers projected the number of cases that would have occurred had the pre-vaccination patterns continued as the nation's population increased.

The journal article is one example of the kind of analysis that can be done when enormous data sets are built and mined. The project, which started in 2009, required assembling 88 million reports of individual cases of disease, much of it from the weekly morbidity reports in the library of the Centers for Disease Control and Prevention. Then the reports had to be converted to digital formats.

Most of the data entry — 200 million keystrokes — was done by Digital Divide Data, a social enterprise that provides jobs and technology training to young people in Cambodia, Laos and Kenya.

Still, data entry was just a start. The information was put into spreadsheets for making tables, but was later sorted and standardized so it could be searched, manipulated and queried on the project's website.

"Collecting all this data is one thing, but making the data computable is where the big payoff should be," said Dr. Irene Eckstrand, a program director and science officer for the N.I.H.'s Models of Infectious Disease Agent Study.

The University of Pittsburgh researchers also looked at death rates, but decided against including an estimate in the journal article, largely because death certificate data became more reliable and consistent only in the 1960s, the researchers said.

But Dr. Donald S. Burke, the dean of Pittsburgh's graduate school of public health and an author of the medical journal article, said that a reasonable projection of prevented deaths based on known mortality rates in the disease categories would be three million to four million.

The scientists said their research should help inform the debate on the risks and benefits of vaccinating American children.

Pointing to the research results, Dr. Burke said, "If you're anti-vaccine, that's the price you pay."

The medical journal article notes the recent resurgence of some diseases as some parents have resisted vaccinating their children. For example, the worst whooping cough epidemic since 1959 occurred last year, with more than 38,000 reported cases nationwide.

The disease data is on the project's website, available for use by other researchers, students, the news media and members of the public who may be curious about the outbreak and spread of a particular disease. Much of the data is searchable by disease, year and location. The project was funded by the National Institutes of Health and the Bill and Melinda Gates Foundation.

"I'm very excited to see what people will find in this data, what patterns and insights are there waiting to be discovered," said Dr. Willem G. van Panhuis, an epidemiologist at Pittsburgh and lead author of the journal article.

The project's name itself is a nod to the notion that data is a powerful tool for scientific discovery. It is called Project Tycho, after the 16th century Danish nobleman Tycho Brahe, whose careful, detailed astronomical observations were the foundation on which Johannes Kepler made the creative leap to devise his laws of planetary motion.

The open-access model for the project at Pittsburgh is increasingly the pattern with government data. The United States government has opened up thousands of data sets to the public.

Just how these assets will be exploited commercially is still in the experimental stage, other than a few well-known applications like using government weather data for forecasting services and insurance products.

But the potential seems to be considerable. Last month, the McKinsey Global Institute, the research arm of the consulting firm, projected that the total economic benefit to companies and consumers of open data could reach $3 trillion worldwide.

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