Court Confronts Religious Rights of Corporations

WASHINGTON — Hobby Lobby, a chain of crafts stores, closes on Sundays, costing its owners millions but honoring their Christian faith.

The stores play religious music. Employees get free spiritual counseling. But they do not get free insurance coverage for some contraceptives, even though President Obama's health care law requires it.

Hobby Lobby, a corporation, says that forcing it to provide the coverage would violate its religious beliefs. A federal appeals court agreed, and the Supreme Court is set to decide on Tuesday whether it will hear the Obama administration's appeal from that decision or appeals from one of several related cases.

Legal experts say the court is all but certain to step in, setting the stage for another major decision on the constitutionality of the Affordable Care Act two years after a closely divided court sustained its requirement that most Americans obtain health insurance or pay a penalty.

"The stakes here, symbolically and politically, are very high," said Douglas Laycock, a law professor at the University of Virginia, citing the clash between religious teachings and the administration's embattled health care law.

In weighing those interests, the Supreme Court would have to assess the limits of a principle recognized in its 2010 decision in Citizens United, which said corporations have free speech rights under the First Amendment. The question now is whether corporations also have the right to religious liberty.

In ruling for Hobby Lobby, the United States Court of Appeals for the 10th Circuit said it had applied "the First Amendment logic of Citizens United."

"We see no reason the Supreme Court would recognize constitutional protection for a corporation's political expression but not its religious expression," Judge Timothy M. Tymkovich wrote for the majority.

A dissenting member of the court, Chief Judge Mary Beck Briscoe, wrote that the majority's approach was "nothing short of a radical revision of First Amendment law."

But Judge Harris L Hartz, in a concurrence, said the case was in some ways easier than Citizens United. "A corporation exercising religious beliefs is not corrupting anyone," he wrote.

Among Hobby Lobby's lawyers is Paul D. Clement, who led the 2012 Supreme Court challenge to the health care law. The new case opened another front in a larger war on the law, which, as Hobby Lobby put it in its Supreme Court brief, "imposes massive obligations on individuals and corporations alike in the process of attempting to fundamentally reorder the nation's health care system."

Mr. Clement's main adversary in the 2012 case, Solicitor General Donald B. Verrilli Jr., told the justices that the 10th Circuit's "unprecedented ruling" in this case would allow "for-profit corporations to deny employees the health coverage to which they are otherwise entitled by federal law, based on the religious objections of the individuals who own a controlling stake in the corporations."

The Supreme Court is generally receptive to appeals from the solicitor general, especially when a lower court has effectively held a federal law unconstitutional. The justices are also apt to step in when, as here, lower courts are divided on an important legal question. Even Hobby Lobby, which won in the appeals court, agrees that the justices should hear the administration's appeal.

"This is a perfect storm," said Richard Garnett, a law professor at Notre Dame, adding that it is also a worrisome one. "Debates about campaign finance in Citizens United and abortion and Obamacare," he said, "could distort the court's analysis of religious freedom."

Hobby Lobby was founded in 1970 in Oklahoma City by David Green, and it now has more than 500 stores and 13,000 employees of all sorts of faiths. Mr. Green and his family own Hobby Lobby through a privately held corporation.

The Greens told the justices in their brief that some drugs and devices that can prevent embryos from implanting in the womb are tantamount to abortion and that providing insurance coverage for those forms of contraception would make the company and its owners complicit in the practice. They said they had no objection to 16 other forms of contraception approved by the Food and Drug Administration, including condoms, diaphragms, sponges, several kinds of birth control pills and sterilization surgery.

But Hobby Lobby's failure to offer comprehensive coverage could, it said, subject it to federal fines of $1.3 million a day. Dropping insurance coverage for its employees, it added, would be disruptive and unfair and lead to fines of $26 million a year.

Mr. Verrilli countered that requiring insurance plans to include comprehensive coverage for contraception was justified by the government's interest in "the promotion of public health" and in ensuring that "women have equal access to health care services." Doctors rather than employers should decide which form of contraception is best, he added.

The administration has excluded many religious organizations from the law's requirements; it has grandfathered some insurance plans that had not previously offered the coverage; and, under the health care law, small employers need not offer health coverage at all. In June, a federal judge in Tampa, Fla., estimated that a third of Americans are not subject to the requirement that their employers provide coverage for contraceptives.

But the administration drew a line at larger, for-profit, secular corporations.

"Congress has granted religious organizations alone the latitude to discriminate on the basis of religion in setting the terms and conditions of employment, including compensation," the Justice Department told the 10th Circuit appeals court, in Denver.

"No court has ever found a for-profit company to be a religious organization for purposes of federal law," the brief went on. "To the contrary, courts have emphasized that an entity's for-profit status is an objective criterion that allows courts to distinguish a secular company from a potentially religious organization, without conducting an intrusive inquiry into the entity's religious beliefs."

The appeals court disagreed, ruling that Hobby Lobby is a "person" for purposes of the relevant federal law, the Religious Freedom Restoration Act of 1993.

Religious liberty, Judge Tymkovich wrote, cannot turn on whether money changes hands. "Would an incorporated kosher butcher really have no claim to challenge a regulation mandating non-kosher butchering practices?" he asked.

Other federal appeals courts considering challenges to the health care law's so-called contraception mandate have ruled that the 1993 law does not apply to corporations.

After finding that Hobby Lobby was entitled to the law's protections, the 10th Circuit went on to say that the company's sincere religious beliefs had been compromised without good reason, noting the limited number of contraception methods at issue and the many employers exempt from the law's requirements.

Professor Laycock said that only one thing was certain about the issues presented in the case, Sebelius v. Hobby Lobby Stores, No. 13-354.

"They're almost sure to take it," he said of the justices, "and no one has any idea how it's going to come out."

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Medicaid Expansion Faces Major Logistical Challenges Among the Homeless

CHICAGO — In a back room at the Franciscan House of Mary and Joseph, one of the largest homeless shelters in Chicago, a social worker named Sheena Ward guided Terry Cannon through a Medicaid application.

A wet cough punctuated Mr. Cannon's often wry answers to Ms. Ward's questions about his disability status, military service and marital history. "I have glaucoma, I'm going blind. I have lung disease, I'm dying," he said. "How can they deny me? If they do, give me a couple years and I'll be gone."

Today, most state Medicaid programs cover only disabled adults or those with dependents, so Mr. Cannon and millions of other deeply impoverished Americans are left without access to the program. But starting Jan. 1, President Obama's health care law will expand Medicaid coverage to adults with incomes under 138 percent of the federal poverty line, and enrollment is expected to increase by about nine million next year. Thousands of homeless people will be among the newly covered.

Housing advocates say they believe that the Medicaid expansion has the potential to reduce rates of homelessness significantly, both by preventing low-income Americans from becoming homeless as a result of illness or medical debt and by helping homeless people become eligible for and remain in housing.

"We really feel like this is the last piece of the puzzle that we need to end chronic homelessness," said Steve Berg, the vice president for programs and policy at the National Alliance to End Homelessness.

But signing up homeless people for Medicaid is a huge logistical challenge, as housing advocates acknowledge. Homeless individuals often do not have an email address, phone number or permanent address. Many are unaware of the health care law or are skeptical of public programs.

Housing advocates and social workers across the country are now on a major push to inform impoverished and homeless people that they are eligible for Medicaid in the 25 states that are expanding the program and in the District of Columbia, and to enroll them.

For homeless people, experts said, the Medicaid expansion will mean more consistent treatment for medical conditions, including alcoholism, drug addiction, chronic pain and depression. For states and cities, they said, it will mean a more effective safety net, and perhaps even a cheaper one.

"You cannot successfully treat someone for diabetes if they're living under a bridge," said Ed Blackburn, the executive director of Central City Concern, a nonprofit agency in Portland, Ore. "And serious mental illness and chronic health conditions are barriers to getting housing."

To help spread the word, Heartland Alliance, the nonprofit organization where Ms. Ward works, has stationed employees in soup kitchens, shelters and medical clinics to increase awareness and encourage enrollment. "They're accustomed to a no," Ms. Ward said of her homeless clients. "You really have to encourage them and let them know it's their right to be covered."

The conditions of homeless life can also make it difficult to enroll. At the House of Mary and Joseph, Julie Nelson, associate director of outreach, benefits and entitlements at Heartland Alliance, huddled with 48-year-old Marvin Cosper. "I heard about Obamacare," he said, nodding, as Ms. Nelson walked him through the basics of the available plans.

But when she explained that it might take 60 days for him to be enrolled, he bristled. "I'm just passing through," he said.

Mr. Cosper is a former drug addict and onetime crack cocaine dealer who has spent much of the past 20 years homeless, moving from state to state. "I was under the impression it was federal," he said. "I thought it was federal, so whatever state you were in, you could use that card."

"That's a really good question," Ms. Nelson said. "It goes state by state." About half of states have opted out of the Medicaid expansion, a decision made possible by the Supreme Court's 2012 ruling on the law.

Mr. Cosper decided to sign up for Medicaid anyway.

Another client, Donna Terrell, who is 54 and has been homeless for a decade, worked with Ms. Nelson to sort out whether she was enrolled already.

"I'm in limbo," Ms. Terrell said, settling onto a cot with a plastic mattress in a room that would hold about 40 women that night. She said she had filled out the paperwork but had never received an enrollment card, ending up with $6,000 in medical bills instead. She and Ms. Nelson determined that Ms. Terrell did have coverage, but her card had been sent to a shelter that had shut down months before.

If the logistical challenges of signing up homeless people for Medicaid can be mitigated, housing advocates and social workers say, the Medicaid expansion could provide profound benefits for them, even though some experts caution that finding doctors who accept Medicaid will continue to be a challenge in many states.

Studies suggest that most chronically homeless Americans are uninsured. It can be logistically difficult for people with very low or nonexistent incomes to gain access even to charity care and free clinics, because getting there costs money and because clinics' hours and ability to provide care are limited.

The Medicaid expansion is expected to greatly improve access to care for hundreds of thousands of homeless Americans, who would be able to see physicians and specialists, often at no cost.

It might also shift the burden of care from emergency rooms to doctors' offices, with benefits for state budgets. Homeless people tend to use health care services in the most expensive ways, said Jennifer Ho, a senior adviser at the Department of Housing and Urban Development. "They show up when they're sicker," she said. "They stay longer. And it's harder to discharge them because they don't have a place to go."

Housing advocates emphasized that the Medicaid expansion would not directly help homeless people find housing. But officials at federal agencies, national housing organizations and local nonprofit organizations pointed to several ways it could reduce rates of homelessness.

In addition to helping prevent homelessness due to medical debt or untreated illness, the expansion could free up money for nonprofit groups to spend on housing, rather than on health care, officials at the National Alliance to End Homelessness said.

The expanded coverage might also make it easier for homeless people to find and stay in housing. For instance, some housing units require prospective tenants to have Medicaid, Ms. Nelson said. Moreover, the expanded Medicaid program would "pay for services that help people become stable so that they can remain in housing," said Karen Batia, the executive director of Heartland Alliance's health outreach operations.

"It's a means to an end," said Ms. Ward, the social worker, adding that it would help organizations like Heartland "treat the person holistically."

Some states might try to bring down medical costs by asking the federal government for waivers to spend Medicaid dollars on supportive housing, experts said.

But first, the challenge is expanding Medicaid to a fragile and hard-to-reach population.

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Critic’s Notebook: MTV’s ‘Generation Cyro’ Links Families

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Well: Antiviral Drugs, Found to Curb Flu Deaths in Children, Fall in Use

The flu can lead to serious complications, even death, in children, but relatively few studies have assessed the effectiveness of antiviral treatments in young patients hospitalized with the infection.

Now a large study, published Monday in the journal Pediatrics, has found that prompt use of antiviral medications like Tamiflu or Relenza can save the lives of flu-stricken children in intensive care units — yet the drugs are being used less frequently than they once were.

"Antivirals matter and they decrease mortality, and the sooner you give them the more effectively they do that," said Dr. Peggy Weintrub, the chief of pediatric infectious diseases at the University of California, San Francisco, who was not involved in the research. "We didn't have nice proof on a large scale until this study."

Researchers at the California Department of Public Health and the federal Centers for Disease Control and Prevention analyzed the medical records of nearly 800 children hospitalized with influenza in that state from April 2009 through September 2012. Six percent of the 653 children treated with drugs called neuraminidase inhibitors died, compared with 8 percent of 131 children who did not receive antiviral treatment.

Since 2009, the year of the H1N1 flu pandemic, the C.D.C. has recommended prompt treatment with antiviral drugs for all hospitalized patients with suspected or confirmed influenza. The directive includes children, especially those who have conditions like asthma, diabetes or heart disease that heighten their risk of severe influenza.

But the authors of the new study found that while 90 percent of critically ill children got antiviral drugs during the pandemic, just 63 percent received them in the two-year period after the pandemic starting September 2010.

"Antiviral use has decreased since the pandemic," said Dr. Janice K. Louie, the lead author of the study and a public health medical officer at the California Department of Public Health. "One of the goals of the study was to increase awareness and remind clinicians that antiviral use is important in this population."

There is wide agreement that the message has not been getting through.

"When the pandemic occurred, there was a lot of publicity, and physicians were being hit over the head with, 'This is a severe disease; you need to be on top of it,' " said Dr. John Treanor, the chief of infectious diseases at University of Rochester Medical Center in New York. Now, he added, "people aren't talking about it."

Dr. Michael Brady, the chairman of the committee on infectious diseases at the American Academy of Pediatrics, said he was not surprised that antivirals were no longer "top of mind" for doctors treating these children. Parents of children with confirmed influenza, and certainly those in intensive care, should ask about antivirals, he said.

"There isn't a sense of urgency," he said. "But this article is saying, 'Your patients would have a lower risk of dying and prolonged hospitalization if you used these medications.' "

Dr. Carl Eriksson, a pediatric critical care specialist at Doernbecher Children's Hospital in Portland, Ore., said physicians might not be aware of the C.D.C. directive. Alternately, he said, "it's possible that doctors are unconvinced by the evidence."

The results of past observational studies looking at the benefit of antiviral drugs in hospitalized children have been mixed. Randomized trials are lacking and difficult to conduct, since researchers cannot deny a treatment likely to be helpful, if neglected, to sick children.

Dr. Nathan Kuppermann, the chairman of the emergency medicine department at University of California, Davis, said administering antiviral drugs to children in the intensive care unit was a "no-brainer."

"Emergency department physicians have a relatively low threshold to use these drugs" for flu-stricken children at high risk for complications, he said. Low-risk children do not need antivirals, he added; overuse could lead to drug resistance.

Some doctors wait for a confirmation of influenza, which can take as long as a couple of days, before starting antivirals, Dr. Weintrub said. But speed matters: Treatment within 48 hours of the appearance of symptoms like fever, cough, sore throat and shortness of breath increased the odds of survival, the new study found.

Parents of a child at high risk for flu complications should call a pediatrician if their child is exposed to a confirmed case of influenza, Dr. Weintrub said.

"For example, if someone has a child with a neurological condition and the mother gets the flu, the child should take antiviral drugs," she said. "It's a very underutilized way of preventing disease."

The authors of the new study acknowledged that H1N1 cases might have been underreported in their sample, since reporting was voluntary. And it was not always clear whether doctors were giving antivirals to the sickest children or the least ill, which might have skewed the results.

Several experts noted that despite the new findings, the most effective way to prevent flu and its complications is vaccination. "I don't think that can be overstated," Dr. Eriksson said.

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Prototype: In the Health Law, an Open Door for Entrepreneurs

In the weeks since the health insurance marketplaces of the Affordable Care Act went online, a well-publicized ripple of alarm and confusion has permeated the ranks of small-business owners. But less well known is the response of another contingent: newcomers to entrepreneurship who see the legislation as a solution to the often insurmountable expense of getting health insurance. Some even view the Affordable Care Act itself as a business opportunity.

The hopeful include founders of start-ups who otherwise wouldn't have access to affordable health insurance — people like Rajeev Jeyakumar, a co-founder of Skillbridge, a Manhattan-based online job marketplace for business consultants.

Mr. Jeyakumar is uninsured. But unlike many people who were thwarted by the government's faulty health care website, he was able to sign up for individual coverage three weeks ago. He will pay just $74 a month, after tax credits, for his new plan through the New York State exchange.

His story illustrates how, when finances are tight, new entrepreneurs often place the health of their businesses over their own health. "In the early days, a venture is often very much self-funded," Mr. Jeyakumar says. "You always trade off between the money you need to survive in terms of paying rent and food. And when you have health care as an additional cost, it's always very tempting to not put money into it."

But come January, Mr. Jeyakumar will have a health plan that "even includes dental," he wrote in an email. "I'm very pleased with the outcome." Until then, he's refraining from using his Citi Bike membership or playing sports, lest he sustain an injury requiring medical care.

And when it's time to hire employees, he says he will most likely avoid the extra work of administering a company health insurance plan and instead encourage employees to shop the new health care exchanges on their own and bump up their salaries to cover the cost.

Research published in the journal Health Affairs showed that small businesses with 10 to 24 employees have paid 10 percent more than large ones for the same health care coverage, and that companies with fewer than 10 employees have paid 18 percent more until now. Small businesses' plans were also more vulnerable to rate increases; as a result, they often provided less coverage, if they offered it at all, resulting in a competitive disadvantage in hiring.

Constantia Petrou, owner of Konnectology, a website that provides information on health care specialists, expects the new law to broaden her hiring options. When she started her company seven years ago in Burlingame, Calif., she realized that she couldn't afford to offer a group plan.

"In terms of hiring, the health care expenses contribute a huge, huge component to your cost of operation," Ms. Petrou says. So instead of bringing on full-time employees, she relied on contract workers.

She is looking forward to getting price information online from the Small Business Health Options Program, or SHOP, an exchange that was created by the new law. (Currently, business owners can obtain estimated SHOP prices online, but specific ones are only available by mail after filling out and mailing in a PDF downloaded from Healthcare.gov. Some states, including California, have their own SHOP exchanges, and their procedures vary.)

Ms. Petrou says the law could enable her to hire full-time employees, depending on the new costs of coverage. If so, she will either pay for a portion of the individual plans that her employees shop for on the exchange, or she may take advantage of tax credits and offer a small group plan. "We now have options to explore," she says.

Some experts say this type of flexibility may have a big impact on the economy over all.

"Assuming we get the website working, it's going to be the biggest step we've had in a long time in the U.S. in terms of changing the structure of the economy," says Craig Garthwaite, assistant professor of management and strategy at Northwestern University's Kellogg School of Management. Mr. Garthwaite is a co-author of one of two recent studies that conclude that the Affordable Care Act could spur entrepreneurship by easing job lock — where people stay in a job mainly for the health insurance.

The act was aimed at people like Jeannie Armstrong, who in 2009 was planning to quit her job within a couple of years to start a private clinic for adolescents with substance-abuse problems. But then her 18-year-old son learned that he had diabetes. Fearing that he would be unable to find individual health insurance, she has stayed in her job so her son could keep receiving coverage under her employer's health plan.

"We're talking pre-existing condition, we're talking no money, we're talking health care costs out of the roof," Ms. Armstrong says of her son's situation.

But in January, her son will be eligible for individual health insurance. That will free Ms. Armstrong to quit her job as a social worker in the juvenile court system of Fairfax County, Va., and to pursue her entrepreneurial dreams. Now, instead of opening a for-profit clinic, Ms. Armstrong has decided to go the social-entrepreneurship route. In September, she founded the nonprofit Center to End Adolescent Substance Abuse Encounters.

Over the next year, she plans to stay in her job while her son finishes school; in her free time, she will assemble a board of directors and write the organization's bylaws. By next fall, she plans to be running the nonprofit full time.

"I'm not hamstrung by having to stay in this job," she says.

Ms. Armstrong sees the new law as an opportunity to start something new. But Kevin Kuhlman, manager of legislative affairs for the National Federation of Independent Business, says that while job lock is a real concern for entrepreneurs, he remains skeptical that the new law will be able to solve the problem.

The federation unsuccessfully challenged the constitutionality of the Affordable Care Act's requirement that most people obtain health insurance or pay a tax penalty,  in a case that went all the way to the Supreme Court last year. The plaintiffs were uninsured and didn't believe that the government could require them to buy insurance.

Certainly, many established small-business owners are not clamoring for information on new health coverage. Barry Sloane, chairman and chief executive of Newtek Business Services, based in New York, says a majority of his customers
haven't bothered to visit the exchanges.

"The negative publicity that's come out about the site not functioning has kept people from thinking they can go to it and get a result," Mr. Sloane says.

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Adrienne Asch, Bioethicist and Pioneer in Disability Studies, Dies at 67

Adrienne Asch, an internationally known bioethicist who opposed the use of prenatal testing and abortion to select children free of disabilities, a stance informed partly by her own experience of blindness, died on Tuesday at her home in Manhattan. She was 67.

The cause was cancer, said Randi Stein, a longtime friend.

At her death, Professor Asch was the director of the Center for Ethics and the Edward and Robin Milstein professor of bioethics at Yeshiva University in Manhattan. She also held professorships in epidemiology and population health and in family and social medicine at Yeshiva's Albert Einstein College of Medicine.

"She certainly was one of the pioneers in disability studies," Eva Feder Kittay, a distinguished professor of philosophy at Stony Brook University and a scholarly colleague of Professor Asch's, said in an interview. "She was a very strong voice, always bringing in the disability perspective, trying to change the view of disability as some tragedy that happens to someone, rather than just another feature and fact about human existence."

Professor Asch, who was trained as a philosopher, social worker, social psychologist and clinical psychotherapist, produced scholarship that stood at the nexus of bioethics, disability studies, reproductive rights and feminist theory.

She maintained that the lives of disabled women should be as much a feminist concern as those of able-bodied ones. Disabled women, she argued, had long been doubly marginalized: first because of their sex, and again because they failed to conform to a collective physical ideal — an ideal to which at least some able-bodied feminists subscribed.

Professor Asch's scholarship centered in particular on issues of reproduction and the family. In an age of fast-moving reproductive technologies, she found that those concerns dovetailed increasingly with issues of disability rights.

She became widely known for opposing prenatal testing as a means of detecting disabilities, and abortion as a means of selecting babies without them.

Professor Asch supported a woman's right to abortion. (She was a past board member of the organization now known as Naral Pro-Choice America.) But in her lectures, writings and television and radio appearances, she argued against its use to pre-empt the birth of disabled children. She argued likewise for prenatal testing.

For her, supporting abortion in general while opposing it in particular circumstances posed little ideological conflict. The crux of the matter, she argued, lay in the difference between a woman who seeks an abortion because she does not want to be pregnant and one who seeks an abortion because she does not want a disabled child.

In the first case, Professor Kittay explained, "you're not seeking to abort 'this particular child.' " In the second, she said, "when you're seeking to abort because of disability, it's not 'any potential child,' it's this child, with these particular characteristics."

Adrienne Valerie Asch was born in New York City on Sept. 17, 1946. A premature baby, she lost her vision to retinopathy in her first weeks.

When she was a girl, her family moved to New Jersey, then one of the few states that let blind children attend school with their sighted peers. She attended public schools in Ramsey, in Bergen County.

On graduating from Swarthmore College with a bachelor's degree in philosophy in 1969, she found employers unwilling to hire her — an experience, her associates said, that made her keenly aware of disability as a civil rights issue.

After receiving a master's degree in social work from Columbia in 1973, she spent much of the '70s and '80s working for the New York State Division of Human Rights, where she investigated employment discrimination cases, including those involving disability.

Trained as a psychoanalytic psychotherapist in the 1980s, she maintained a private psychotherapy practice throughout that decade. In 1992, she received a Ph.D. in social psychology from Columbia.

Before joining the Yeshiva faculty, Professor Asch taught at the Boston University School of Social Work and at Wellesley College, where she was a professor of women's studies and the Henry R. Luce Professor in biology, ethics and the politics of human reproduction.

Her publications include two volumes of which she was a co-editor: "Women With Disabilities: Essays in Psychology, Culture, and Politics" (1988, with Michelle Fine) and "Prenatal Testing and Disability Rights" (2000, with Erik Parens).

A resident of the Upper West Side of Manhattan, Professor Asch is survived by a brother, Carl, and a sister, Susan Campbell.

In an article in The American Journal of Public Health in 1999, Professor Asch laid out her philosophy in no uncertain terms.

"If public health espouses goals of social justice and equality for people with disabilities — as it has worked to improve the status of women, gays and lesbians, and members of racial and ethnic minorities — it should reconsider whether it wishes to continue the technology of prenatal diagnosis," she wrote.

She added: "My moral opposition to prenatal testing and selective abortion flows from the conviction that life with disability is worthwhile and the belief that a just society must appreciate and nurture the lives of all people, whatever the endowments they receive in the natural lottery."

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Selling That New-Man Feeling

One afternoon a few months ago, a 45-year-old sales representative named Mike called "The Dr. Harry Fisch Show," a weekly men's health program on the Howard Stern channel on Sirius XM Radio, where no male medical or sexual issue goes unexplored.

"I feel like a 70-year-old man in a 45-year-old body," Mike, from Vancouver, British Columbia, told Dr. Fisch on the live broadcast. "I want to feel good. I don't want to feel tired all day."

A regular listener, Mike had heard Dr. Fisch, a Park Avenue urologist and fertility specialist, talk about a phenomenon called "low testosterone" or "low T." Dr. Fisch likes to say that a man's testosterone level is "the dipstick" of his health; he regularly appears on programs like "CBS This Morning" to talk about the malaise that may coincide with low testosterone. He is also the medical expert featured on IsItLowT.com, an informational website sponsored by AbbVie, the drug maker behind AndroGel, the best-selling prescription testosterone gel.

Like many men who have seen that site or commercials or online quizzes about "low T," Mike suspected that diminished testosterone was the cause of his lethargy. And he hoped, as the marketing campaigns seem to suggest, that taking a prescription testosterone drug would make him feel more energetic.

"I took your advice and I went and got my testosterone checked," Mike told Dr. Fisch. Mike's own physician, he related, told him that his testosterone "was a little low" and prescribed a testosterone medication.

Mike also said he had diabetes and high blood pressure and was 40 pounds overweight. Dr. Fisch explained that conditions like obesity might be accompanied by decreased testosterone and energy, and he urged Mike to exercise more and to lose weight. But if Mike had trouble overhauling his diet and exercise habits, Dr. Fisch said, taking testosterone might give him the boost he needed to do so.

"If it gives you more energy to exercise," Dr. Fisch said of the testosterone drug, "I'm all for it."

Recommendations like Dr. Fisch's and the marketing of low T as a common medical condition helped propel sales of testosterone gels, patches, injections and tablets to about $2 billion in the United States last year, according to IMS Health, a health care information company. In 2002, sales were reported to be a mere $324 million; around that time, Solvay Pharmaceuticals, which was then marketing AndroGel, began using the term "low T," replacing a previous euphemism for male aging, "andropause." Today the low-T trend is global. From 2000 to 2011, there was "a major and progressive increase" in testosterone use in 37 countries, according to a recent study published in the Medical Journal of Australia.

This marketing juggernaut is running into mounting opposition from some prominent medical researchers and industry experts. They contend that the pharmaceutical industry has vastly expanded the market for testosterone drugs to many men who may not need them and may be exposed to increased health risks by taking them. And drug makers have done so, these critics say, by exploiting loopholes in federal marketing regulations.

Drug makers spent $107 million last year to advertise the top brand-name testosterone drugs in the United States, according to Kantar Media. That amount doesn't include marketing known as unbranded campaigns, which raise awareness of low T itself. The Food and Drug Administration closely regulates advertisements for brand-name prescription drugs, but does not generally regulate unbranded campaigns. That two-track system, says John Mack, an analyst who runs a blog called Pharma Marketing, has enabled companies to position low T as a malady with such amorphous symptoms — listlessness, increased body fat and moodiness — that it can be seen to afflict nearly all men, at least once in a while. Drug makers also promote low-T screening quizzes directly to consumers, Mr. Mack says, in an effort to prompt men to seek testosterone prescriptions from their doctors.

"You might not have the medical condition as described in the textbook," Mr. Mack explains. "But you may have low T as defined by marketing quizzes, and you go to the doctor and ask for treatment."

David Freundel, a spokesman for AbbVie, declined requests to interview company executives. In a statement, Mr. Freundel wrote: "AndroGel is approved by the F.D.A. to treat adult men with low or no testosterone (hypogonadism) who have been diagnosed by a physician, and has more than 10 years of clinical, safety, published and post-marketing data." He added that the company continues to finance research into the long-term effects of testosterone therapy and that its unbranded informational efforts, like the IsItLowT.com site, "follow F.D.A.'s guidance."

Nevertheless, some public health experts warn that the popularization of testosterone drugs is outpacing research into efficacy and possible harms. The drugs' labels warn users about the potential for sleep apnea, congestive heart failure and low sperm counts; the topical gels warn that women and children exposed to the substances could develop male characteristics like chest hair. Others have raised concerns about the potential for prostate cancer and heart attacks.

"The big thing is, we just don't know the long-term risk of testosterone therapy at this time," says Jacques G. Baillargeon, an epidemiologist at the University of Texas Medical Branch at Galveston who has studied testosterone-prescribing trends in the United States. "It's particularly concerning when you see the dramatic increase happening at such a large scale so quickly."

Seeking a Fountain of Youth

In a TV commercial promoting awareness of "low T," the shadow of a middle-age man sits on a bench watching his friends play basketball in an indoor gym.

"Feeling like a shadow of your former self? Don't have the hops for hoops with your buddies?" says the voice-over for the spot, paid for by AbbVie and currently posted on the IsItLowT site. "You might have a treatable condition called low testosterone or low T."

A few seconds later, presumably after the man is treated with testosterone, the shadow evaporates and a man materializes in the flesh, besuited and smiling. Cue the voice-over: "Step out of the shadows."

Testosterone, which plays a central role in the development of the male sexual organs, as well as muscle and body hair, has long been a synonym for youthful vigor and virility. And the quest to stave off aging by manipulating the hormone is an old business.

Toward the end of the 19th century, Charles-Édouard Brown-Séquard, a French physiologist, began injecting himself with "juice" extracted from crushed dog or guinea-pig testicles, as reported in The Lancet in 1889. Although he contended that the injections were rejuvenating, subsequent researchers came to believe that the placebo effect was at work.

In the 1920s and '30s, surgeons began transplanting monkey and goat testes into men, says Dr. John E. Morley, the director of endocrinology and geriatrics at the Saint Louis University School of Medicine. But that fad ended quickly after one well-known surgeon implanted goat testicles into his patients, where they apparently emitted a noxious odor.

"This is the hilarious history of testosterone," recounts Dr. Morley, who in the past received speaking fees or consulting fees from drug makers that marketed testosterone treatments or planned to do so. "It may not have gotten any better. But, gee whiz, it was crazy."

Researchers were eventually able to synthesize testosterone, and drug makers capitalized on the discovery by using it to develop medical treatments.

The classic endocrine disorder for which testosterone drugs were originally developed and federally approved is called hypogonadism. That condition can be caused by problems like undescended testicles or a tumor in the pituitary gland, typically resulting in severe testosterone deficiency, along with poor libido, minimal muscles and scant body hair. "That is the real hypogonadal patient," says Dr. Richard Quinton, an endocrinologist at Newcastle University in Britain, "not the overweight businessman whose erections aren't as good as they used to be."

In fact, physicians weren't precisely quantifying men's testosterone levels until the 1960s, after the development of sensitive tests to determine the concentration of different hormones in blood samples. These enabled researchers to record men's testosterone levels over time. Dr. Morley and others have reported that, after age 30, men's testosterone levels typically decline by 1 percent a year. To the pharmaceutical industry, that decline was ripe for treatment.

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Sleep Therapy Is Expected to Gain a Wider Role in Depression Treatment

Katie Orlinsky for The New York Times

Shelby Harris, the director of the behavioral sleep medicine program at Montefiore Medical Center. "There aren't many of us doing this therapy," Dr. Harris said, but that may change soon.

An insomnia therapy that scientists just reported could double the effectiveness of depression treatment is not widely available nor particularly well understood by psychiatrists or the public. The American Board of Sleep Medicine has certified just 400 practitioners in the United States to administer it, and they are sparse, even in big cities.

That may change soon, however. Four rigorous studies of the treatment are nearing completion and due to be reported in coming months. In the past year, the American Psychological Association recognized sleep psychology as a specialty, and the Department of Veterans Affairs began a program to train about 600 sleep specialists. So-called insomnia disorder is defined as at least three months of poor sleep that causes problems at work, at home or in relationships.

The need is great: Depression is the most common mood disorder, affecting some 18 million Americans in any given year, and most have insomnia.

"I think it's increasingly likely that this kind of sleep therapy will be used as a possible complement to standard care," said Dr. John M. Oldham, chief of staff at the Menninger Clinic in Houston. "We are the court of last resort for the most difficult-to-treat patients, and I think sleep problems have been extremely underrecognized as a critical factor."

The treatment, known as cognitive behavioral therapy for insomnia, or CBT-I, is not widely available. Most insurers cover it, and the rates for private practitioners are roughly the same as for any psychotherapy, ranging from $100 to $250 an hour, depending on the therapist.

"There aren't many of us doing this therapy," said Shelby Harris, the director of the behavioral sleep medicine program at Montefiore Medical Center in the Bronx, who also has a private practice in Tarrytown, N.Y. "I feel like we all know each other."  

According to preliminary results, one of the four studies has found that when CBT-I cures insomnia — it does so 40 percent to 50 percent of the time, previous work suggests — it powerfully complements the effect of antidepressant drugs.

"There's been a huge recognition that insomnia cuts across a wide variety of medical disorders, and there's a need to address it," said Michael T. Smith, a professor at the Johns Hopkins School of Medicine and president of the Society of Behavioral Sleep Medicine.

The therapy is easy to teach, said Colleen Carney, director of the sleep and depression lab at Ryerson University in Toronto, whose presentation at a conference of the Association for Behavioral and Cognitive Therapies in Nashville on Saturday raised hopes for depression treatment. "In the study we did, I trained students to administer the therapy," she said in an interview, "and the patients in the study got just four sessions."

CBT-I is not a single technique but a collection of complementary ideas. Some date to the 1970s, others are more recent. One is called stimulus control, which involves breaking the association between being in bed and activities like watching television or eating. Another is sleep restriction: setting a regular "sleep window" and working to stick to it. The therapist typically has patients track their efforts on a standardized form called a sleep diary. Patients record bedtimes and when they wake up each day, as well as their perceptions about quality of sleep and number of awakenings. To this the therapist might add common-sense advice like reducing caffeine and alcohol intake, and making sure the bedroom is dark and quiet.

Those three elements — stimulus control, restriction and common sense — can do the trick for many patients. For those who need more, the therapist applies cognitive therapy — a means of challenging self-defeating assumptions. Patients fill out a standard questionnaire that asks how strongly they agree with statements like: "Without an adequate night's sleep, I can hardly function the next day"; "I believe insomnia is the result of a chemical imbalance"; and "Medication is probably the only solution to sleeplessness." In sessions, people learn to challenge those beliefs, using evidence from their own experiences.

"If someone has the belief that if they don't sleep, they'll somehow fail the next day, I'll ask, 'What does failure mean? You'll be slower at work, not get everything done, not make dinner?' " Dr. Harris said. "Then we'll look at the 300 nights they didn't sleep well over the past few years and find out they managed; it might not have been as pleasant as they liked, but they did not fail. That's how we challenge those kinds of thoughts."

Dr. Aaron T. Beck, an emeritus professor of psychiatry at the University of Pennsylvania who is recognized as the father of cognitive therapy for mental disorders, said the techniques were just as applicable to sleep problems. "In fact, I have used it myself when I occasionally have insomnia," he said by email.

In short-term studies of a month or two, CBT-I has been about as effective as prescription sleeping pills. But it appears to have more staying power. "There's no data to show that if you take a sleeping pill — and then stop taking it — that you'll still be good six months later," said Jack Edinger, a professor at National Jewish Health in Denver and an author, with Dr. Carney, of "Overcoming Insomnia: A Cognitive-Behavioral Therapy Approach."

"It might happen, but those certainly aren't the people who come through my door," he said.

Dr. Edinger and others say that those who respond well to CBT-I usually do so quickly — in an average of four sessions, and rarely more than eight. "You're not going to break the bank doing this stuff; it's not a marriage," he said. "You do it for a fixed amount of time, and then you're done. Once you've got the skills, they don't go away."

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Extra Time to Sign Up for Health Coverage

WASHINGTON — The Obama administration said Friday that it would give people eight more days, until Dec. 23, to sign up for health insurance coverage that takes effect on Jan. 1 under the new health care law.

Julie Bataille, a spokeswoman for the federal Centers for Medicare and Medicaid Services, said the government recognized that consumers might need more time to compare and select health insurance plans because of technical problems that have plagued the online federal insurance marketplace since it opened on Oct. 1.

The administration also said it would delay the 2015 insurance enrollment period for the Affordable Care Act by a month, pushing it beyond the 2014 elections.

The decision means that people who have not signed up for insurance by the end of March will generally have to wait until Nov. 15, 2014, to apply. The second enrollment period was previously scheduled to begin on Oct. 15, 2014.

Jeffrey D. Zients, President Obama's troubleshooter on the federal exchange repair effort, said Friday that the performance of the website, as measured by response times and error rates, was improving. But he and Ms. Bataille were unable to say how many people were now enrolling.

Enrollment started slowly last month, with just over 106,000 people picking private plans through the federal and state insurance marketplaces. The administration has said it expects seven million people to sign up for such plans by the end of the six-month open enrollment period on March 31.

The original deadline required people to sign up by Dec. 15 for coverage beginning in January. Though the new deadline for such coverage is Dec. 23, Ms. Bataille said that consumers would have until Dec. 31 to pay their share of premiums for the first month.

Insurers and Obama administration officials said they expected to see a large number of people sign up in December, meaning that the government and insurers may need to process a lot of applications in a short time. Whether the federal website, HealthCare.gov, can handle the demand is unclear.

Mr. Zients said that the website could now handle 25,000 users at the same time and would be able to handle 50,000 by the end of this month. At times, he predicted, the demand "will exceed this capacity." At those times, he said, consumers can queue up to use the website, or they can ask the government to send them "email notifications when it's a better time to come back to the site."

When the website went live Oct. 1, officials at the White House and the Health and Human Services Department knew of tests showing it could not handle more than 2,000 users at once, according to emails released this week by the House Committee on Energy and Commerce.

The House Republican leader, Representative Eric Cantor of Virginia, criticized the administration's decision to delay the start of the next open enrollment period beyond the 2014 elections.

He said Mr. Obama did not want voters to see higher premiums just before they went to the polls. "If Obamacare is so great," Mr. Cantor asked, "why are Democrats so scared of voters knowing its consequences?"

The administration also said Friday that insurers would get an extra month to set their rates and file applications for health plans to be sold in 2015. The White House press secretary, Jay Carney, said the delay would help insurers evaluate their experience in 2014 and use it to set rates for 2015. "This gives them more time to assess the pool of people who are getting insurance through the marketplaces and make decisions about what rates will look like in the coming year," he said.

The Commonwealth Fund, a foundation that specializes in health policy, said Friday that the pace of enrollment was picking up, based on data reported by state exchanges.

"The latest enrollment figures from the 14 states that are running their own marketplaces show that enrollment has climbed to at least 200,000 people nationwide," said Sara R. Collins, a vice president of the fund.

So far, she said, states report that 173,268 people have signed up in their exchanges, and the Obama administration said last week that 26,794 people had selected plans in the federal exchange.

In a manual describing the enrollment process for states using the federal exchange, the Obama administration says that a consumer is not formally enrolled in a health plan until the insurer receives payment of the first month's premium. Insurers must begin coverage on Jan. 1 for consumers who have paid their share of the initial month's premium by Dec. 31, the manual says. Likewise, if a consumer signs up by Feb. 15 and pays the premium by Feb. 28, officials said, the insurer must begin coverage on March 1.

The executive director of Hawaii's exchange, Coral Andrews, announced her resignation on Friday. The state-run exchange has faced problems like those that have plagued the federal insurance website.

Though the Hawaii exchange website was to open on Oct. 1, software problems kept it dark until Oct. 15. As of Nov. 15, only 257 people had enrolled through the Hawaii exchange.

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Frederick Sanger, 95, Twice a Nobel Laureate and a Genetics Pioneer, Dies

Frederick Sanger, a British biochemist whose discoveries about the chemistry of life led to the decoding of the human genome and to the development of new drugs like human growth hormone, earning him two Nobel Prizes, a distinction held by only three other scientists, died on Tuesday in Cambridge, England. He was 95.

His death was confirmed by Adrian Penrose, communications manager at the Medical Research Council in Cambridge. Dr. Sanger lived in a nearby village called Swaffham Bulbeck.

Dr. Sanger won his first Nobel Prize, in chemistry, in 1958 for showing how amino acids link together to form insulin. The discovery gave scientists the tools to analyze any protein in the body.

In 1980 he received his second Nobel, also in chemistry, for inventing a method of "reading" the molecular letters that make up the genetic code. This discovery was crucial to the development of biotechnology drugs and provided the basic tool kit for decoding the entire human genome two decades later.

Unusual for someone of his stature, Dr. Sanger spent his entire career in a laboratory. Long after receiving his first Nobel, he continued to perform many experiments himself instead of assigning them to junior researchers as is typical in modern science labs. Dr. Sanger said he was not particularly adept at coming up with experiments for others to do and had little aptitude for administration or teaching.

"I was in a position to do more or less what I liked, and that was doing research," he said.

Frederick Sanger was born on Aug. 13, 1918, in Rendcomb, England, where his father was a physician. He expected to follow his father into medicine, but after studying biochemistry at Cambridge University, he decided to become a scientist. His father, he said in a 1988 interview, "led a scrappy sort of life" in which he was "always going from one patient to another."

"I felt I would be much more interested in and much better at something where I could really work on a problem," he said.

He received his bachelor's degree in 1939. Raised as a Quaker, he was a conscientious objector on religious grounds during World War II and remained at Cambridge in those years to work on his doctorate, which he received in 1943.

Later in life, however, he became an agnostic, saying he lacked hard evidence to support his religious beliefs.

"In science, you have to be so careful about truth," he said. "You are studying truth and have to prove everything. I found that it was difficult to believe all the things associated with religion."

Dr. Sanger stayed on at Cambridge and became immersed in the study of proteins. When he started his work, scientists knew that proteins were chains of amino acids, fitted together like a child's colorful snap-bead toy. But there are 22 different amino acids, and scientists had no way of determining the sequence of these amino acid "beads" along the chains.

Dr. Sanger decided to study insulin, a protein that was readily available in a purified form for the treatment of diabetes. His choice of insulin turned out to be a lucky one: with 51 amino acid beads, insulin has a relatively simple structure. Still, it took him 10 years to unlock its chemical sequence.

His approach, which he called the "jigsaw puzzle method," involved breaking insulin into manageable chunks for analysis and then using his knowledge of chemical bonds to fit the pieces back together. Using this technique, scientists went on to determine the sequences of other proteins. Dr. Sanger received the Nobel just four years after he published his results in 1954.

In 1962, Dr. Sanger moved to the British Medical Research Council Laboratory of Molecular Biology, where he was surrounded by scientists studying deoxyribonucleic acid, or DNA, the master chemical of heredity.

Scientists knew that DNA, like proteins, had a chainlike structure. The challenge was to determine the order of adenine, thymine, guanine and cytosine — the chemical bases from which DNA is made. These bases, which are represented by the letters A, T, G and C, spell out the genetic code for all living things.

Dr. Sanger quickly discovered that his jigsaw method was too cumbersome for large pieces of DNA, which contain many thousands of letters. "For a while I didn't see any hope of doing it, though I knew it was an important problem," he said.

But he persisted, developing a more efficient approach that allowed stretches of 500 to 800 letters to be read at a time. His technique, known as the Sanger method, increased by a thousand times the rate at which scientists could sequence DNA.

In 1977, Dr. Sanger decoded the complete genome of a virus that had more than 5,000 letters. It was the first time the DNA of an entire organism had been sequenced. He went on to decode the 16,000 letters of mitochondria, the energy factories in cells.

Because the Sanger method lends itself to computer automation, it has allowed scientists to unravel ever more complicated genomes — including, in 2003, the three billion letters of the human genetic code, giving scientists greater ability to distinguish between normal and abnormal genes.

Dr. Sanger shared the 1980 chemistry Nobel with two other scientists: Paul Berg, who determined how to transfer genetic material from one organism to another, and Walter Gilbert, who, independently of Dr. Sanger, also developed a technique to sequence DNA. Because of its relative simplicity, the Sanger method became the dominant approach.

Other scientists who have received two Nobels are John Bardeen for physics (1956 and 1972), Marie Curie for physics (1903) and chemistry (1911), and Linus Pauling for chemistry (1954) and peace (1962).

Dr. Sanger received the Albert Lasker Basic Medical Research Award, often a forerunner to the Nobel, in 1979 for his work on DNA. He retired from the British Medical Research Council in 1983.

Survivors include two sons, Robin and Peter, and a daughter, Sally.

In a 2001 interview, Dr. Sanger spoke about the challenge of winning two Nobel Prizes.

"It's much more difficult to get the first prize than to get the second one," he said, "because if you've already got a prize, then you can get facilities for work, and you can get collaborators, and everything is much easier."

Daniel E. Slotnik contributed reporting.

This article has been revised to reflect the following correction:

Correction: November 23, 2013

An obituary on Thursday about the biochemist Frederick Sanger misstated his date of birth. He was born on Aug. 13, 1918 — not on Aug. 3.

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