Mystery Virus That’s Killed 47 Is Tied to Bats in Saudi Arabia

Jonathan H. Epstein/EcoHealth Alliance

A match to the virus was found in a fecal sample of this type of bat, the Taphozous perforatus.

WASHINGTON — Health officials confirmed Wednesday that bats in Saudi Arabia were the source of the mysterious virus that has sickened 96 people in the Middle East, killing 47 of them.

The outbreak of Middle East Respiratory Syndrome, or MERS, has been going on for 15 months, with most victims falling ill in Saudi Arabia and others growing sick after having traveled to the Middle East. In a study released Wednesday, an international team of doctors blamed coronavirus in bats for the human outbreak, but said that many questions remained, in part because a perfect match for the virus was found in only a single insect-eating bat out of about 100 Saudi bats tested. And since such bats do not normally bite people, drool on fruit or do other things that might transmit the disease to people, it was still unclear how the virus leapt to humans.

The bat is a Taphozous perforatus, or Egyptian tomb bat, which roosts in abandoned buildings, and the virus was found in a fecal sample.

So it is possible, said Dr. Jonathan H. Epstein, a veterinarian with the EcoHealth Alliance who helped trap the bats, that victims, like shepherds who might seek shelter in the buildings, picked it up by breathing in dried bat guano — similar to the way that Americans have been infected with hantavirus while sweeping up dried mouse droppings.

But it is also possible that an animal picked it up that way and then infected a human. Pigs, for instance, can get Nipah virus from bats and then pass it to humans in slaughterhouses.

Further tests on camels, sheep, goats and a cow will be finished soon, said Dr. W. Ian Lipkin, head of Columbia University's Center for Infection and Immunity, which has already done 15,000 polymerase chain reaction tests tracking the virus.

"It's a huge amount of work," he said.

It has been known for several months that bats in Africa and Eastern Europe carried viruses related to MERS, but the relevant virus had not been found in Middle Eastern bats before. Camels in Oman have shown antibodies to a similar virus.

Knowing that one bat had an identical virus is a start, but more testing will be needed, said Dr. Ziad A. Memish, the Saudi deputy health minister who was a co-author on the study and gave a presentation on the virus in Washington on Wednesday.

The infected bat was in an abandoned house in a date palm orchard in Bisha, a small Saudi Arabian city. Investigators from Columbia and EcoHealth Alliance took samples there because the first known victim of the MERS outbreak was a businessman who had lived in Bisha and had his business, a large paint warehouse, nearby. The warehouse had a large garden with fruit trees and insects that attract many kinds of bats. The victim, a wealthy 60-year-old man, got sick in mid-June and died two weeks later, Dr. Lipkin said.

The victim also owned four pet camels that were sampled, but those results are not in yet, Dr. Lipkin added. Samples taken from livestock in countries with endemic foot-and-mouth disease must first be delivered to an Agriculture Department laboratory on Plum Island, Mass., to be certified negative for foot-and-mouth before they can be released for further testing.

Those restrictions can add months to the testing process, Dr. Memish said. That is one reason the bat samples were tested sooner, although other problems emerged: one of two frozen shipments of bat samples – the one the positive bat was in – was opened at Customs on entry into the United States and had thawed out by the time it reached Dr. Lipkin's lab 48 hours later.

What was recovered from that sample, however, was a 100 percent match, which is virtually unheard of in virology, the study said.

The victim from Bisha had separate houses for his three wives and was building a fourth for a woman he planned to marry, "which suggests he was still vigorous," Dr. Lipkin said.

But most of those killed by the new virus were old and had chronic conditions like diabetes or heart disease. Cases are being found of younger, healthier victims who often have milder symptoms, according to Dr. Memish, so it may soon be established that the disease's mortality rate is much lower than 60 percent.

In his presentation Wednesday, hosted in Washington by the University of Pittsburgh Medical Center's Center for Health Security, Dr. Memish said he only learned of the existence of the new virus in his own country when he read about it late last September on ProMED, an outbreak-alert service.

Dr. Memish said that by then, it was too late to advise travelers not to come to the annual pilgrimage to Mecca, which draws 4.5 million pilgrims. "That put an incredible strain on our system," he said.

His department ordered all Saudi hospitals to look for and report unusual cases of pneumonia. The virus does not spread easily from person to person, but there have been case clusters in which family members or nurses and doctors who cared for patients were infected.

This year, the kingdom has suggested that older people, very young children and those in ill health or with suppressed immune systems not make the pilgrimage.

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U.P.S. to End Health Benefits for Spouses of Some Workers

United Parcel Service has told its white-collar employees that it will stop providing health care coverage to their spouses who can obtain coverage through their own employers, joining an increasing number of companies that are restricting or eliminating spousal health benefits.

U.P.S., the world's largest package delivery company, said its decision was prompted in part by "costs associated with" the federal health care law that is commonly called Obamacare. Several health care experts, however, said they believed the company was motivated by a desire to hold down health care costs, rather than because of cost increases under the law.

In a memo addressed to employees, U.P.S. said, "Limiting plan eligibility is one way to manage ongoing health care costs, now and into the future, so that we can continue to provide affordable coverage for our employees."

The memo also estimated that about 33,000 spouses were covered under its insurance plan for white-collar employees and that "about 15,000 of these would have health care coverage available through their own employers."

In explaining its move — which was first reported by Kaiser Health News and USA Today — U.P.S. told employees, "Since the Affordable Care Act requires employers to provide affordable coverage, we believe your spouse should be covered by their own employer — just as U.P.S. has a responsibility to offer coverage to you, our employee."

"In an effort to maintain premiums at or below current cost," Andrew McGowan, a U.P.S. spokesman, said, "U.P.S. made a change that affects a limited number of employees."

U.P.S. is one of the biggest companies so far to drop spousal coverage for some segment of its work force, and its announcement was viewed by some as a harbinger of a broader trend in employers' restrictions on health care benefits.

Large employers like Xerox and Teva Pharmaceuticals already impose surcharges for spousal coverage. And some cities, like Terre Haute, Ind., decided to follow what many of its private corporations were doing, by adopting a "spousal carve-out" so that working spouses would not be covered under its health plans.

The limits on coverage are occurring as some cities and companies are also considering changes to coverage for retirees under 65 and not eligible for Medicare, who might be shifted to the health insurance exchanges being established in states under the Obama health care law.

While the percentage of employers adopting changes in policies like U.P.S.'s new limits remains in the single digits, it is growing. According to a corporate survey by Mercer, a consulting firm, 6 percent of companies with 500 or more employees excluded coverage for spouses in 2012 if their spouses could obtain coverage through their own employer. That is double the percentage in 2008, Mercer found.

Mercer's survey also found that 6 percent of employers required a surcharge for workers who keep their spouses on their health coverage even though their spouses could obtain coverage from their own employer. A Towers Watson survey found that 33 percent of large employers said they would impose such a surcharge by 2015.

The new U.P.S. policy does not apply to the children of those employees. Nor does it affect the company's 250,000 unionized workers, who belong to the International Brotherhood of Teamsters. At the end of last year, the company had around 399,000 employees.

Several health care experts said companies were taking these moves partly because the federal health care law does not require employers to provide spousal coverage, but does require them to offer it to employees and their children. U.P.S. made clear that it would continue to provide coverage to spouses who did not have it through another employer.

Assessing U.P.S.'s new policy, Gary Claxton, a vice president and health care expert at the Kaiser Family Foundation, said, "It's clear that it's a competitive industry, and they want to cut costs."

Barry Schilmeister, a senior health consultant at Mercer, said one reason more employers were embracing this policy was to help avoid being hit by the so-called Cadillac tax, which imposes a 40 percent tax on health care premiums above a certain threshold. In 2018, when that tax takes effect, the threshold will be $10,200 for individual coverage and $27,500 for family coverage.

"The Cadillac tax is going to be a serious extra cost for plans that exceed a certain level," Mr. Schilmeister said. He added that with this move, "U.P.S. is in an indirect way addressing its overall costs — it's going to lower its total exposure by potentially covering fewer people."

Mr. Schilmeister predicted that many companies would shun the policy because it posed numerous problems. "It's not going to be a popular move among employees," he said.

He added that it would put many employers and employees in an uncomfortable position, with companies that adopt this policy often requiring employees to sign an affidavit affirming that their spouse was not being offered health coverage by another employer.

Many corporations have complained that their health costs would rise as a result of various provisions of the Affordable Care Act, like the requirement that insurance plans cover workers' children up to age 26 and the prohibition against a lifetime cap on the amount insurance plans would pay for an employee's health care. Both those provisions took effect in 2010.

Joanne Peters, a spokeswoman for the Department of Health and Human Services, pointed to numerous studies that predicted that employers would continue to offer coverage notwithstanding the law's requirements.

Moreover, premiums have been rising modestly, she said. In a survey of employers released on Tuesday, the Kaiser Family Foundation found that the average annual premium for a family rose 4 percent in 2013, to $16,351.

Mr. Claxton, the vice president with the Kaiser Family Foundation, said he doubted provisions like the requirement to insure employers children up to age 26 were creating strains on U.P.S. and other companies.

"Those things are trivial in terms of expenses — just pennies per month," Mr. Claxton said.

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Well: U.S. Circumcision Rates Are Declining

The percentage of newborns who are circumcised in the United States declined to 58.3 percent in 2010 from 64.5 percent in 1979, according to a new analysis from the National Center for Health Statistics. The report is based on annual surveys of about 450 hospitals nationwide.

But rates varied over the period. They went down during the 1980s after a task force of the American Academy of Pediatrics found that there were no medical benefits to the procedure, then rose during the '90s after the medical group revised its position, claiming there were potential benefits. In 1999, the A.A.P. changed its view again, stating that despite potential benefits, there was insufficient evidence to recommend routine circumcision. That announcement was followed by another slight decrease.

There are regional variations as well. In 2010, about 71 percent of babies in the Midwest were circumcised, 66.3 percent in the Northeast, 58.4 percent in the South, and 40.2 percent in the West.

The lead author of the report, Maria Owings, a health statistician with the center, emphasized that the report includes no explanation for the numbers. "We didn't factor in any other contextual information that would shed light on the reasons for the regional variations or the variations over time," she said. And, she added, "The N.C.H.S. doesn't take an advocacy position."

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Well: At the Chiropractor, Well-Adjusted Pets

One morning last August, Mary Arabe's 9-year-old gray and black tiger cat, Leo, came home from a night out exploring with a severe limp and an elbow swollen three times its normal size. He was clearly in pain; Ms. Arabe thought he had dislocated his shoulder during a fall.

"He kind of lay around the barn that day; you could tell he was hurting," said Ms. Arabe, who lives on a 25-acre farm in Rogers, Ohio, with 10 chickens, three horses, three cats and two dogs. "He was in so much agony I thought, 'If someone can't remove this animal's pain I have to put him down.'"

She took Leo to the veterinarian, who said he could do nothing for him. Despondent, she took him to Rick Tsai, a chiropractor in Darlington, Pa., who a few years earlier had adjusted Ms. Arabe's puggle, Bustar, after a head and neck injury.

An X-ray found no broken bones, but there was a large amount of swelling and fluid retention. Dr. Tsai couldn't make any promises, but he placed his hands on the cat's spine, hips and neck and manipulated the joints until they popped.

"We brought the cat home, and the next day he was walking fine," said Ms. Arabe. "Two thirds of the swelling in the arm was gone. Whatever Dr. Tsai adjusted, it worked. He healed him."

Millions of people swear by their chiropractors, and chiropractic has long been a mainstay in the equine world, especially among show or racehorses. Now it is gaining popularity among pet owners, as a way to treat household pets suffering from arthritis, sprains, joint pain and other ailments.

Animal, or veterinary, chiropractic originated around 1895, when human chiropractic first began. But it did not gain wider appeal until 1987, when the late Sharon Willoughby-Blake, a veterinarian and chiropractor, started Options for Animals in Hillsdale, Ill., which taught vets and chiropractors how to adjust animals. Two years later, the American Veterinary Chiropractic Association, a professional membership group and the main certifying agency in North America, was formed.

According to Robbie Hroza, vice president of operations for Options for Animals, about 2,000 students have gone through their program. Over the last two years, student enrollment has increased by 50 percent; a good portion are recent graduates of veterinary or chiropractic schools, she said.

Still, the practice remains controversial, in both people and pets. While some studies have found that chiropractic care can be more effective than medications for people with problems like neck pain, others have linked forceful neck manipulation to strokes. Other researchers have found that unfavorable chiropractic outcomes are under-reported in medical trials.

There are only a few scientific studies about chiropractic's efficacy on animals, and tensions exist both within and between the chiropractic and veterinary communities. The American Holistic Veterinary Medical Association, a trade organization, reports that in 2012 about 900 of the estimated 97,000 veterinarians in the United States practiced some type of animal adjustment.

In some states a chiropractor is not allowed to touch an animal without either a veterinarian's referral or direct veterinary supervision. And in its pain management guidelines for dogs and cats, the American Animal Hospital Association and the American Association of Feline Practitioners caution, "chiropractic methods potentially can cause injury through the use of inappropriate technique or excessive force."

"There is currently insufficient published evidence of efficacy in dogs and cats to make specific recommendations about the use of chiropractic intervention," they add.

Indeed, since 1994, the American Chiropractic Association's position has been that the term "veterinary chiropractic" is a misnomer and should "not be used to refer to the application of manipulative techniques to animals."

To get around it, many veterinary practitioners use other monikers, at least for official purposes. At The Healing Oasis Wellness Center in Sturtevant, Wis., students are trained in "veterinary spinal manipulative therapy"; enrollment has tripled since opening in 1993, according to co-owner Michelle Rivera.

The American Veterinary Chiropractic Association calls the 1,000 plus vets and chiropractors that have gone through its training "AVCA certified doctors."

Dr. William L. Inman, a veterinary surgeon and head of the International Association of Veterinary Chiropractitioners (also known as the American Animal Adjusting Association) in Coeur D'Alene, Idaho, offers "veterinary orthopedic manipulation," or VOM, which involves applying a six-inch long, stainless steel, rubber-tipped Activator-like device on an animal's spinal column. The 8,300 people who have gone though his course earn the title of "certified veterinary chiropractitioner."

Many chiropractors think the rules are unfair to pet owners. "A person should be allowed to take their animal anywhere they want if they think it benefits them," said Dr. Tsai, the chiropractor who treated Ms. Arabe's cat. He has worked in tandem with veterinarians over the years, but acknowledges that many of them don't like his field because it takes business away from them.

"Do you really think that a few weeks course can possibly teach a vet the skills that has taken a good chiropractor years to learn?" said Dr. Tsai, who has adjusted everything from raccoons to owls out of his home office in East Palestine, Ohio.

Gene Giggleman, a veterinarian, animal chiropractor and a professor of anatomy at Parker University College of Chiropractic, in Dallas, which has trained more than 400 vets and chiropractors in animal chiropractic, thinks it's more about a lack of knowledge. "My philosophy as a vet is 'chiropractic first, drugs and surgery second,' but a lot of vets don't understand or know about animal chiropractic, and so they don't refer people," he said.

Other veterinarians say their reservations are more about the health of the animal.

Dave Geiger, a veterinary neurologist near Santa Fe, believes that animal chiropractic has the potential to be harmful because "it's performed by practitioners who often have very little background knowledge of veterinary neurology — or veterinary medicine at all — and thus are unable to fairly evaluate the theoretical or actual effects of their practices."

"Some practitioners even promote veterinary chiropractic for conditions that it is potentially dangerous for, like degenerative disc disease," he added. "It should be clearly identified as an unproven therapy, and practitioners should be prevented from making claims about its effects."

Still, as with most kinds of alternative therapy, adherents often can't be swayed.

"If it's good enough for us, why not them?" said Dee Hayes, a yoga instructor in San Diego who shared the same chiropractor with her cocker spaniel, Charlie, for six years.

Patricia Kallenbach, a holistic veterinarian in Crystal River, Fla., said the field is growing because the client base demands it. "They're saying, 'If I'm going to eat better, I'm going to get my pet to eat better,'" she said. "'If I can benefit from chiropractic care on my body, so can my pet.'"

Chiropractic also tends to be much cheaper than veterinary care, with visits costing as little as $35, depending on the type of animal and, of course, the practitioner.

To that end, learning another modality is beneficial to veterinarians, many of whom have been struggling financially. "It's a practice builder in that you can offer another service without a huge amount of training," said Dr. Kallenbach, who recently added chiropractic, massage therapy and acupuncture to her practice (in addition to massage for humans).

Maureen Wilkins and her 6-year-old Russian Peterbald cat, Isak, both get adjustments from Shannon Gaertner-Ewing, a chiropractor in Nampa, Idaho. Ms. Wilkins, 60, had been seeing Dr. Gaertner-Ewing herself on a weekly basis and started bringing in Isak three years ago.

"Isak is inclined to get grumpy, and it's my understanding that's usually because he's hurting," said Ms. Wilkins, a retired teacher who pays $20 per visit. "So, when Isak gets particularly grumpy and starts beating up on his feline brother or he jumps someplace and then falls off, we take him to Dr. G. She adjusts him, and it's like Dr. Jekyll and Mr. Hyde. His attitude improves, he becomes Mr. Cuddles. He can't get enough affection."

Ms. Wilkins maintains that Isak can sense in advance when it's time to visit Dr. Gaertner-Ewing. "When I put down the car carrier he'll leap into it," she said. "He is thrilled to go. As soon as he sees her, he's practically drooling."

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Books: Pregnant, and Disputing the Doctor

During her pregnancy, Emily Oster didn't appreciate her doctor's habit of issuing blanket rules: Don't gain more than 35 pounds. No need to discuss amniocentesis — you're not 35. No eating in the delivery room.

An edict to limit coffee to two cups a day particularly irked Dr. Oster, a health economist at the University of Chicago whose workday was powered by a "pretty steady caffeine drip."

Her ob-gyn issued decrees without explanation, much as a parent says "no" and expects compliance. But Dr. Oster, a Ph.D. trained in statistics who is not a medical doctor, could not imagine making an informed decision without some data. Her new book is the result of weekends sifting through PubMed and other scientific databases; reading a textbook, Steven Gabbe's "Obstetrics"; and chewing over issues with friends in the field to figure out which pregnancy rules were supported by convincing evidence.

"Expecting Better" will be a revelation for curious mothers-to-be whose doctors fail to lay out the pros and cons of that morning latte, let alone discuss real science. And it makes for valuable homework before those harried ob-gyn appointments, even for lucky patients whose doctors are able to talk about the rationale behind their advice.

But her confrontational approach may well alienate some readers, not to mention doctors, and some experts are questioning the accuracy of her advice on alcohol.

Some of myths she attempts to explode were already on the ropes. It's widely known that bed rest — recommended to supposedly prevent preterm labor — is supported by little evidence and could cause harm. And Dr. Oster, 33, notes that "fertility declines with age, but not as fast as you might expect." But as luck would have it, she got scooped by an article in The Atlantic that argued — with statistics — that a decline in fertility in a woman's 30s has been oversold.

She's on fresher terrain dissecting two tests performed late in pregnancy. The nonstress test, done to assess fetal distress, depends on measurements of the heart rate and the fetus' movements. Simply clapping loudly can wake the fetus and get her moving. Good to know.

And if an ultrasound finds that amniotic fluid is too low, Dr. Oster writes, there are two possible solutions. Make sure the so-called deepest vertical pocket is being measured; alternately, drinking two liters of water before the test can raise amniotic fluid levels. That's useful advice, especially since a low reading can lead to induced labor.

Yet some of her conclusions are less well supported by medical research. After reviewing small studies showing that exercise has little impact on rates of C-sections, fetal growth or labor length, she concludes that exercise is "fine" for pregnant women but so is abstaining for nine months. The latter approach overlooks the broad health benefits of exercise, pregnant or not.

Dr. Oster's thoughts on drinking alcohol while expecting have already generated controversy. In her view, there is no good scientific evidence that light drinking negatively impacts the fetus. Pregnant women can be comfortable with "1 to 2 drinks a week in the first trimester" and one drink daily afterward, she writes.

Similar assertions have long been made, but her explanation may be unique: a woman who drinks slowly lowers the amount of alcohol and acetaldehyde, its toxic byproduct, reaching her fetus.

Most government agencies and the American College of Obstetricians and Gynecologists say that no amount of alcohol has been proved safe for the developing fetus, a position Dr. Oster calls "draconian."

Bill Dunty, a program director of the division of metabolism and health effects at the National Institute on Alcohol Abuse and Alcoholism, called her explanation "oversimplified" and said it could "potentially mislead women to think they are not exposing their fetus to alcohol."

Women vary in their ability to absorb and metabolize alcohol, according to Dr. Dunty. "It is unrealistic to believe that an individual can inherently control the amount of alcohol or its metabolites that reach her fetus by taking longer time to drink an alcoholic beverage," he said.

Dr. Oster contends that acetaldehyde is processed "by the baby's liver and doesn't get into the brain."

However, the fetal liver is not formed until at least week 20, and it doesn't become fully functional until just before birth, says Jacquelyn Bertrand, a senior scientist at the National Center on Birth Defects and Developmental Disabilities at the Centers for Disease Control and Prevention.

What's more, ethanol crosses the placenta and becomes part of the amniotic fluid, said Dr. Bertrand, who has a Ph.D. in psychology and has studied the neurodevelopment of children with prenatal alcohol exposure. Even with very slow drinking, ethanol builds up in the amniotic fluid. which bathes fetal tissue for a considerable time, she said, adding that all fetal organs, especially the brain, are very vulnerable because sometimes they are in direct contact with amniotic fluid.

Throughout "Expecting Better," Dr. Oster paints a fairly antagonistic picture of the doctor-patient relationship, castigating what she views as the restriction of women's freedom.

Dr. Jeffrey L. Ecker, the chairman of the committee on obstetrics practice for A.C.O.G., acknowledged that doctors used to take a "directive approach of 'Do this, don't do that, end of story.'" But now, he said, relationships with expectant patients have evolved into more of a "shared decision-making model."

"I wouldn't equate offering a recommendation, even a recommendation that doesn't have the strongest possible evidence, with restricting someone's freedom," Dr. Ecker said.

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Tacking Health Care Costs Onto California Farm Produce

Matt Black for The New York Times

In the Central Valley of California, farm workers in a tomato field. Insurance brokers and health providers estimate that meeting the Affordable Care Act's minimum health plan will cost about $1 per hour per employee in the field.

HURON, Calif. — Farm labor contractors across California, the nation's biggest agricultural engine, are increasingly nervous about a provision of the Affordable Care Act that will require hundreds of thousands of field workers to be covered by health insurance.

While the requirement was recently delayed until 2015, the contractors, who provide farmers with armies of field workers, say they are already preparing for the potential cost the law will add to their business, which typically operates on a slender profit margin.

"I've been to at least a dozen seminars on the Affordable Care Act since February," said Chuck Herrin, owner of Sunrise Farm Labor, a contractor based here. "If you don't take the right approach, you're wiped out."

The effects of the law could be profound. Insurance brokers and health providers familiar with California's $43.5 billion agricultural industry estimate that meeting the law's minimum health plan requirement will cost about $1 per hour per employee worked in the field.

"Everybody is afraid of the cost," said J. Edward McClements, Jr., a senior vice president at Barkley Insurance and Risk Management, based in Oxnard, about 60 miles west of Los Angeles. "It's difficult when you've got 1,000 workers who've never had health insurance before, to get an idea of what their costs will be."

The concern is felt from vineyards in Napa County to the almond orchards outside Coalinga in the Central Valley. Farm labor contractors generally rely on a 2 percent profit, and they say they will have to pass the added health care costs required by the law on to growers.

Mr. Herrin, who can employ up to 2,000 farmworkers — many of them longtime employees — has been warning his customers of the coming price increase due to health insurance costs.

"It's made for some heated battles," Mr. Herrin said of his talks with growers, who include his father-in-law, the owner of a Central Valley farm.

Some farmers seem resigned to higher labor costs. "That cost is going to be borne by us at the end of the day," said Scott Deardorff, a partner at Oxnard-based Deardorff Family Farms, which grows strawberries, cauliflower and chard, among other salad bar staples, all of which are likely to be more expensive for consumers down the line.

Across the country, employers in many other kinds of businesses are devising strategies to comply with or, in some cases, sidestep a new requirement to provide insurance for those who work 30 hours or more. Some are breaking their businesses into smaller companies, for instance, or even laying off workers. Some companies plan to shift workers to part-time status.

But in the vast, fertile fields of California's Central Valley, part-time labor is not realistic. Pruning, picking and packing produce is full-time, nearly year-round work.

"You can't put your ag workers on a 28-hour workweek like Starbucks, Denny's and Walmart are considering," Mr. McClements said.

In places like Huron, a Central Valley town surrounded by thousands of acres of farmland, there are other, practical concerns.

On a recent morning, Jose Romero pulled weeds from a row of lush tomato plants. Mr. Romero, 36, arrived at the field around 5 a.m. and worked until sunset. Like many of the other workers in the tomato field, he was surprised to learn that his employer, Mr. Herrin at Sunrise Farm Labor, would have to offer him health coverage, and that he could be asked to contribute up to 9.5 percent of his wages to cover the costs.

"We eat, we pay rent and no more," Mr. Romero said in Spanish. "The salary that they give you here, to pay insurance for the family, it wouldn't be enough."

There seems to be widespread agreement among agricultural employers, insurance brokers and health plans in California that low-wage farmworkers cannot be asked to pay health insurance premiums. "He's making $8 to $9 an hour, and you're asking him to pay for something that's he's not going to use?" Mr. Herrin said.

The minimum compliant health plan for employee coverage under the new law will cost about $250 a month in California's growing regions, according to insurance brokers, and includes a $5,000 deductible for medical care, although insurers cannot charge co-payments for preventive visits. "It's unacceptable," Mr. Herrin said of the cost.

The situation is complicated by the reality that many farmworkers apply for jobs with questionable identification, and farmers and farm labor contractors hire them anyway. (Employers say they must accept documents that look legitimate and can be penalized for directly asking if a potential employee is in the country illegally.)

Employers are trying to spread the word, a tricky process in places where the mention of government oversight can stir fear. Oscar Renteria, owner of Renteria Vineyard Management, a farm labor contractor based in Napa, has held meetings in Spanish to explain the health law to his 380 employees, some of whom may be in the country illegally.

"They're really nervous," Mr. Renteria said. "Nervous they'll be tracked and then somehow the possibility of being identified, and the fear of being deported or not being allowed to work. It comes up all the time in conversations when we outline the choices."

This article was produced in collaboration with Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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Well: How Exercise Can Help Us Sleep Better

Phys Ed

Gretchen Reynolds on the science of fitness.

As a clinical psychologist and sleep researcher at Northwestern University's Feinberg School of Medicine, Kelly Glazer Baron  frequently heard complaints from aggrieved patients about exercise. They would work out, they told her, sometimes to the point of exhaustion, but they would not sleep better that night.

Dr. Baron was surprised and perplexed. A fan of exercise for treating sleep problems, but also a scientist, she decided to examine more closely the day-to-day relationship between sweat and sleep.

What she and her colleagues found, according to a study published last week in The Journal of Clinical Sleep Medicine,  is that the influence of daily exercise on sleep habits is more convoluted than many of us might expect and that, in the short term, sleep may have more of an impact on exercise than exercise has on sleep.

To reach that conclusion, Dr. Baron and her colleagues turned to data from a study of exercise and sleep originally published in 2010. For that experiment,  researchers had gathered a small group of women (and one man) who had received diagnoses of insomnia. The volunteers were mostly in their 60s, and all were sedentary.

Then the researchers randomly assigned their volunteers either to remain inactive or to begin a moderate endurance exercise program, consisting of three or four 30-minute exercise sessions per week, generally on a stationary bicycle or treadmill, that were performed in the afternoon. This exercise program continued for 16 weeks.

At the end of that time, the volunteers in the exercise group were sleeping much more soundly than they had been at the start of the study. They slept, on average, about 45 minutes to an hour longer on most nights, waking up less often and reporting more vigor and less sleepiness.

But had the novice exercisers experienced immediate improvements in their sleep patterns, Dr. Baron wondered? And, on a day-to-day basis, had working out on any given day produced better sleep that night?

Boring deep into the data contained in the exercising group's sleep diaries and other information for the new study, Dr. Baron discovered that the answer to both questions was a fairly resounding no. After the first two months of their exercise program, the exercising volunteers (all of them women) were sleeping no better than at the start of the study. Only after four months of the program had their insomnia improved.

They also rarely reported sleeping better on those nights when they had had an exercise session. And perhaps most telling, they almost always exercised for a shorter amount of time on the days after a poor night's sleep.

In other words, sleeping badly tended to shorten the next day's workout, while a full-length exercise session did not, in most cases, produce more and better sleep that night.

At first glance, these results might seem "a bit discouraging," Dr. Baron said. They also would seem to be at odds with the earlier conclusion that four months of exercise improved insomniacs' sleep patterns, as well as a wealth of other recent science that typically has found that  regular exercise lengthens and deepens sleep.

But, Dr. Baron pointed out, most of these other studies employed volunteers without existing sleep problems. For them, exercise and sleep seem to have a relatively uncomplicated relationship. You work out, fatigue your body and mind, and sleep more soundly that night.

But people with insomnia and other sleep disturbances tend to be "neurologically different," Dr. Baron said. "They have what we characterize as a hyper-arousal of the stress system," she said. A single bout of exercise on any given day "is probably not enough to overcome that arousal," she explained, and potentially could even exacerbate it, since exercise is itself a physical stressor.

Eventually, however, if the exercise program is maintained, Dr. Baron said, the workouts seem to start muting a person's stress response. Her or his underlying physiological arousal is dialed down enough for sleep to arrive more readily, as it did in the original 2010 experiment.

Of course, both of these studies were small, involving fewer than a dozen exercising volunteers, all of them middle-aged or older women. "We think the findings would apply equally to men," Dr. Baron said. But that idea has yet to be proven.

Likewise, it is impossible to know yet the sleep-related impacts of workouts of different types(like weight training), intensities or timing, including morning or late-evening sessions.

Still, the preliminary message of these findings is heartening. If you habitually experience insomnia and don't currently exercise, Dr. Baron said, start. Don't, however, expect that you will enjoy or even complete workouts that occur on the day after a broken night's sleep, or that you will sleep better hours after you've exercised.

The process is more gradual and less immediately gratifying than the sleep-deprived might wish. But the benefits do develop. "It took four months" in the original study, Dr. Baron said, but at that point the exercising volunteers "were sleeping at least 45 minutes more a night." "That's huge, as good as or better" than most current treatment options for sleep disturbances, including drugs, she said.

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Health Care Costs Climb Moderately, Survey Says

Premiums for employer-provided health insurance have increased by relatively modest amounts this year, according to a new survey, a further sign that once-torrid health care inflation has abated for now.

The average annual premium for a family rose 4 percent in 2013, to $16,351, according to the survey results released Tuesday by the Kaiser Family Foundation. Annual premiums for individual policies purchased through an employer rose 5 percent, to $5,884.

The 4 percent increase for a family is relatively tame, at least compared with the roughly 10 percent annual increases experienced a decade ago. But it is still a far bigger rise than 1.8 percent increase in wages and the 1.1 percent rate of inflation in the last year, the foundation said.

"If you are comparing it to 10 years ago in health care, it seems modest," said Helen B. Darling, chief executive of the National Business Group on Health, which represents large employers. "If you compare it to the economy and what inflation is doing, I don't think it's modest at all."

The data also suggest that the new health care law is not leading, at least so far, to a rapid escalation of insurance costs.

"The critics will have a much harder time blaming big premium increases in employer insurance on Obamacare this year, because there aren't any big premium increases," Drew Altman, chief executive of the Kaiser foundation, said in a telephone news conference Tuesday.

Conversely, however, it is not clear if the Affordable Care Act, as the law is formally known, has contributed to the moderating of premium increases, Kaiser researchers said.

Premiums have been held in check partly by increasing out-of-pocket costs that workers pay through co-payments and deductibles.

The survey found that 78 percent of covered workers have a general deductible, up from 72 percent in 2012. About 38 percent of covered workers now face a deductible of at least $1,000. At companies with fewer than 200 employees, 58 percent of covered workers have a deductible that large, with 31 percent having a deductible of at least $2,000, up from 12 percent in 2008.

"It's part of what I see as a quiet revolution in health insurance, from more comprehensive to less comprehensive, with higher deductibles," said Dr. Altman, who added that that should appeal to conservatives. "The vision of insurance that they've always favored, with more skin in the game, is the one that's coming to dominate in the marketplace."

While out-of-pocket costs are going up, the proportion of total premiums paid by workers out of their paychecks did not change in the last year, Kaiser said. On average workers paid $4,565, or about 28 percent, of the average family premium and $999, or 17 percent, of the average individual premium.

The survey results showed that employers are not dropping health benefits and forcing their employees to seek coverage on the new exchanges being set up under the Affordable Care Act.

About 57 percent of all companies are offering health benefits this year compared with 61 percent last year, a difference that was not statistically significant. Among companies with three to nine workers, 45 percent offered some benefits compared with 50 percent in 2012, a decline that also was not statistically significant.

The 4 percent increase in family premiums in 2013 was similar to the increase in 2012 and in most of the last several years. But since 1999, premiums have nearly tripled while wages have gone up only 50 percent and consumer prices only 40 percent.

The slower increase in premiums appears to reflect slower growth of health care spending in general that is partly explained by people forgoing visits to doctors and medical procedures because of the bad economy.

There is a debate about whether the Affordable Care Act is contributing to the moderation. It has not gone into effect fully yet, but some health care providers might already be cutting costs in anticipation. At the same time, employers have been asking workers to pay higher deductibles and be more selective

"My general sense is it's too early to take what's happening with health care spending, whether it's for good or bad, and assign it to the A.C.A.," said Martin S. Gaynor, a professor of economics and health policy at Carnegie Mellon University.

Kaiser conducted the survey of more than 2,000 companies of various sizes, with the Health Research and Educational Trust, which is affiliated with the American Hospital Association.

A separate survey that will be released Wednesday, commissioned by the Commonwealth Fund, has found that an estimated 7.8 million young adults are insured because of the Affordable Care Act provision allowing them to be covered by their parents' plan.

The survey found that, contrary to common perceptions, many young adults, age 19 to 29, are interested in health insurance. But it also found that only 27 percent were aware of the new state health insurance marketplaces that are starting Oct. 1.

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Oklahoma Judge Blocks Law Limiting Morning-After Birth Control

A judge in Oklahoma on Monday blocked an attempt by the state's Legislature to restrict access to morning-after birth control pills.

The federal government removed restrictions on the purchase of emergency contraceptives in June. The Oklahoma Legislature subsequently passed a law that required purchasers to show identification and, if age 17 or under, to have a prescription.

The Oklahoma law "would have essentially reimposed" the federal restrictions, said David Brown, staff lawyer for the Center for Reproductive Rights in New York, which sued on behalf of the Oklahoma Coalition for Reproductive Justice and Jo Ann Mangili, the mother of a teenage girl, to overturn the law.

Judge Lisa Davis of Oklahoma County issued a temporary injunction to block enforcement of the law until the case is decided.

"We're disappointed the judge prevented the law from going into effect, said Diane Clay, spokeswoman for the state attorney general, E. Scott Pruitt. "The law simply keeps requirements the same as they have been for more than a decade, requiring those under age 17 to have a prescription to buy Plan B emergency contraceptives."

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18 and Under: College Prep, This Time for Health

To me, the strangest thing about my son's college health forms was that they did not require my signature.

From a medical point of view, an 18-year-old is a legal adult. Yes, parents may offer up pithy remarks about who is actually an adult, and in what sense, and who pays the bills. But when children head off to college, responsibility for their health unmistakably shifts. They must take care of themselves, in every sense, and now is the time to talk about how.

At the last visit before a new student sets off for college, pediatricians like me go over health care topics, from vaccines to the management of chronic conditions to the vicissitudes of temperament. And, of course, we address the perennial collegiate issues of sex, substance abuse and sleep deprivation. This is an opportunity for young adults to think through the joys and risks of leaving home and living with others and, well, growing up.

Students should know their own medical stories — if they're allergic to any drug, for example, they should know exactly what they're allergic to and how it manifests. Anyone with a chronic medical condition — from asthma to diabetes to an eating disorder — should consider having medical records sent to the college health service to keep on file.

"With a lot of students who come in with significant medical histories, we have to go through the process of requesting the medical record," said Dr. Marcy Ferdschneider, the medical director of the student health center at New York University. The delay can make it harder to provide good care in a crisis moment.

(On a more general note, Dr. Ferdschneider also recommends packing thermometers, because so many students call the clinic with a vague but unverified sense that they've had fevers.)

Many students remain on their parents' health insurance plans, even if they choose coverage with their college health services. Though they may use student health services, some insurance plans may require referrals from home doctors for specialists, or want specialists chosen from particular lists. Part of being responsible for your health is knowing about your coverage and carrying your insurance card.

Any young adult heading to college should be fully up-to-date on vaccines. Many of those now routinely received by adolescents were not around when their parents were in college. Dormitory living has long been recognized as a risk factor for meningitis outbreaks, for example. Most children routinely receive two doses of the meningitis vaccine in high school, but anyone who did not should definitely get it before college.

The tetanus-diphtheria-pertussis booster, given to adolescents and adults, protects against whooping cough, another relatively common infection among college students.

The vaccine against human papillomavirus — which causes genital warts, and cervical, penile and anal cancers — is credited with a major decrease in infection rates among adolescents. But despite an excellent safety record, just half of eligible adolescent girls are immunized and many fewer boys receive this vaccine, according to the Centers for Disease Control and Prevention. New students should at least start the series before landing at college. And they should know that a flu shot, as soon as the vaccine becomes available this fall, is another imperative for dormitory life.

Parents, like doctors, must discuss contraception and sexual safety. But ideally the conversation should range further: Talk about adult relationships and the glorious possibility of finding love. Talk — sorry, but you must — about date rape and the dangers of making sexual decisions under the influence of alcohol.

You've presumably discussed alcohol with your child, but bring it up again. If there's a family history of alcoholism and your child isn't familiar with it, this would be a good time to explain your concerns. As with sex, start by talking about safety but then go beyond.

Dr. Megan A. Moreno, an associate professor of pediatrics at the University of Washington, advised that students adopt a buddy system if they go to parties and think they'll be drinking. "Sometimes college students respond more to the idea of protecting your friends, because for yourself you think, 'That'll never happen,' " she said.

Discuss the decisions that your own child must make, but also the experience of watching other people make different choices — and live with the consequences. For many young adults, the question of what to do when a friend or a neighbor seems to be at risk is actually an easier way into a difficult topic.

Emphasize the value of sleep. Talk about how to handle stress.

And think about setting some expectations in terms of communication. How closely do you expect to stay in touch? "Don't hover," said Dr. Larry Neinstein, the executive director of the Engemann Student Health Center at the University of Southern California and the author of a guide, "The Healthy Student: A Parent's Guide to Preparing Teens for the College Years." He suggested this parental approach: "I don't need to know everything moment to moment in your life, but when you really need some advice, feel free to call me at any hour and I will try to help."

For parents, including pediatricians, this is what it means to send a child off to college — or to any new phase of life. You try for reasonable precautions to keep them physically safe, even in the context of new and unexpected adventures. You return to all the important conversations about making reasonably wise choices and getting help when times are hard.

You keep the lines of communication open, you help sort out the paperwork, and then you take a deep breath and hand everything over to the child you love so dearly, now a young adult increasingly in charge.

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