The New Old Age Blog: Training Needed for Home Care Is Lacking

“H” from Chicago, I heard you when you joined a lively discussion over hospice at home here a couple of weeks ago and asked, “where can family members get the training to do all the nursing tasks?”

In the comments section, many readers wrote in to say that caring for relatives at the end of their lives was a duty and a privilege. Others said they were unprepared for the physical and emotional burdens of doing so.

Your question stood out because of its practical character. Do caregivers have to figure out how to handle all these complicated medical issues on their own? Or is some help out there?

For an answer, I called two of the authors of “Home Alone: Family Caregivers Providing Complex Chronic Care,” put out by the United Hospital Fund and the AARP Public Policy Institute. That study recently made headlines by reporting that 46 percent of the nation’s 42 million caregivers handle medical and nursing tasks such as giving injections, caring for wounds or administering I.V.s.

Susan Reinhard, senior vice president and director of the AARP Public Policy Institute, sighed when I reached her, and said “this is a huge gap,” referring to a notable absence of available training in demanding caregiving tasks.

To the extent training exists through local agencies on aging, disease-specific organizations or social service groups, it deals mostly with so-called “activities of daily living” — helping someone bath, dress, eat, or use the bathroom — not the demands of nursing-style care, Ms. Reinhard observed.

Really, this kind of training should be the responsibility of health care providers, but doctors and nurses often give only cursory, unsatisfactory explanations of complex tasks that fall to caregivers, said Carol Levine, director of the Families and Health Care Project of the United Hospital Fund.

That leaves the burden on caregivers to be assertive and ask for help, these experts agreed. If someone is hospitalized and ready to return home, they suggest asking a nurse or another provider “show me what you are doing so I can learn how to do it,” and then asking “now, watch me do it and tell me if I am doing it wrong or right.”

Don’t give up after the first time if you feel awkward or uncomfortable. Ask to do the task again, and ask again for feedback.

No videos or written manuals, can substitute for this one-on-one, hands-on instruction. If you don’t get it to your satisfaction before a loved-one is ready to go home, don’t sign the form that says you have been given instructions on what to do, Ms. Reinhard advised. The hospital is legally obligated to ensure that discharges are safe, and this operates in your favor.

The same goes for the pharmacy: don’t sign that sheet that the pharmacist hands you indicating that you have been adequately informed about the medications you are purchasing. If you are concerned about the number of prescriptions, what they are for, their possible side effects and whether all are necessary, ask the pharmacist to sit down with you and go over all this information. Again, don’t leave until you are satisfied.

Often, caregiving tasks will change as someone with a chronic condition like Parkinson’s disease or heart failure becomes more frail. Should this happen, consider calling a home care agency and asking for a nurse to come out and teach you how to administer oxygen or help transfer someone safely from a bed to a wheelchair, Ms. Reinhard said.

You may want to videotape the session so you can view it several times; most of us don’t pick these skills up right away and need repeat practice, Ms. Levine said.

Be as specific in your request for help as possible. Rather than complaining that you are overwhelmed, say something along the lines of, “I want to make sure I know how to clean this wound and prevent an infection” or “I need to know what texture the food should be so I can feed mom without having her choke,” Ms. Levine suggested.

Her organization has prepared comprehensive materials for caregivers called “Next Step in Care.” While the focus isn’t on nursing-style caregiving tasks, three might be useful: a self-assessment tool for family caregivers, a medication management guide, and a guide to hospice and palliative care.

Other helpful materials are few and far between. Ms. Levine’s staff identified a $24.95 American Red Cross training manual for family caregivers that has a DVD explaining the mechanics of transfers and a few other complicated tasks. Also, some videos are available for free at www.mmlearn.org, a Web site that says its mission is to provide caregivers with online training and education.

Asked about model programs, Ms. Reinhard said she knew of only one: the Schmieding Home Caregiver Training Program in Arkansas, operated by the Donald W. Reynolds Institute on Aging of the University of Arkansas for Medical Sciences. The Schmieding program trains family caregivers as well as professional caregivers who work in people’s homes or nursing homes.

On the family side, it offers eight hours of instruction in “physical needs” associated with caregiving — managing incontinence, skin care, turning someone regularly in bed, using adaptive equipment, transfers from a bed to a wheelchair, helping patients remain mobile, and more. Classes are offered at five sites and four more are planned in the next several years, said Robin McAtee, associate director of the Reynolds Institute on Aging. If people, churches or senior centers want the instruction, which is free, Schmieding nurses will take the program to them. One-on-one instruction for tasks is also available on request.

A separate eight-hour program is available for caregivers dealing with dementia, who have additional concerns.

At a Web site called Elder Stay at Home, Schmieding sells a package of materials (three DVDs and a booklet, for $99) summarizing the content of its family caregiver training program. Separately, it has begun selling its curriculum for paid caregivers, and programs in California, Hawaii and Texas are among the first buyers. The University of Arkansas for Medical Sciences also has received a $3.7 million innovation grant from the government to expand the caregiver training program more broadly and develop online training materials.

Ms. Reinhard said AARP would like to see Schmieding-style programs rolled out across the country and begin to offer structured, reliable support to caregivers now providing nursing-style care in homes with little or no assistance.

What else am I missing here? Do you know of resources or other organizations providing intensive caregiver training along the lines of what I’ve been discussing? Where would you suggest people turn for this kind of help?

Editor’s Note:

Correction: An earlier version of this post contained an incorrect spelling of the first name of the director of the Families and Health Care Project of the United Hospital Fund. She is Carol Levine, not Carole Levine.

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The New Old Age Blog: Training Needed for Home Care Is Lacking

“H” from Chicago, I heard you when you joined a lively discussion over hospice at home here a couple of weeks ago and asked, “where can family members get the training to do all the nursing tasks?”

In the comments section, many readers wrote in to say that caring for relatives at the end of their lives was a duty and a privilege. Others said they were unprepared for the physical and emotional burdens of doing so.

Your question stood out because of its practical character. Do caregivers have to figure out how to handle all these complicated medical issues on their own? Or is some help out there?

For an answer, I called two of the authors of “Home Alone: Family Caregivers Providing Complex Chronic Care,” put out by the United Hospital Fund and the AARP Public Policy Institute. That study recently made headlines by reporting that 46 percent of the nation’s 42 million caregivers handle medical and nursing tasks such as giving injections, caring for wounds or administering I.V.s.

Susan Reinhard, senior vice president and director of the AARP Public Policy Institute, sighed when I reached her, and said “this is a huge gap,” referring to a notable absence of available training in demanding caregiving tasks.

To the extent training exists through local agencies on aging, disease-specific organizations or social service groups, it deals mostly with so-called “activities of daily living” — helping someone bath, dress, eat, or use the bathroom — not the demands of nursing-style care, Ms. Reinhard observed.

Really, this kind of training should be the responsibility of health care providers, but doctors and nurses often give only cursory, unsatisfactory explanations of complex tasks that fall to caregivers, said Carol Levine, director of the Families and Health Care Project of the United Hospital Fund.

That leaves the burden on caregivers to be assertive and ask for help, these experts agreed. If someone is hospitalized and ready to return home, they suggest asking a nurse or another provider “show me what you are doing so I can learn how to do it,” and then asking “now, watch me do it and tell me if I am doing it wrong or right.”

Don’t give up after the first time if you feel awkward or uncomfortable. Ask to do the task again, and ask again for feedback.

No videos or written manuals, can substitute for this one-on-one, hands-on instruction. If you don’t get it to your satisfaction before a loved-one is ready to go home, don’t sign the form that says you have been given instructions on what to do, Ms. Reinhard advised. The hospital is legally obligated to ensure that discharges are safe, and this operates in your favor.

The same goes for the pharmacy: don’t sign that sheet that the pharmacist hands you indicating that you have been adequately informed about the medications you are purchasing. If you are concerned about the number of prescriptions, what they are for, their possible side effects and whether all are necessary, ask the pharmacist to sit down with you and go over all this information. Again, don’t leave until you are satisfied.

Often, caregiving tasks will change as someone with a chronic condition like Parkinson’s disease or heart failure becomes more frail. Should this happen, consider calling a home care agency and asking for a nurse to come out and teach you how to administer oxygen or help transfer someone safely from a bed to a wheelchair, Ms. Reinhard said.

You may want to videotape the session so you can view it several times; most of us don’t pick these skills up right away and need repeat practice, Ms. Levine said.

Be as specific in your request for help as possible. Rather than complaining that you are overwhelmed, say something along the lines of, “I want to make sure I know how to clean this wound and prevent an infection” or “I need to know what texture the food should be so I can feed mom without having her choke,” Ms. Levine suggested.

Her organization has prepared comprehensive materials for caregivers called “Next Step in Care.” While the focus isn’t on nursing-style caregiving tasks, three might be useful: a self-assessment tool for family caregivers, a medication management guide, and a guide to hospice and palliative care.

Other helpful materials are few and far between. Ms. Levine’s staff identified a $24.95 American Red Cross training manual for family caregivers that has a DVD explaining the mechanics of transfers and a few other complicated tasks. Also, some videos are available for free at www.mmlearn.org, a Web site that says its mission is to provide caregivers with online training and education.

Asked about model programs, Ms. Reinhard said she knew of only one: the Schmieding Home Caregiver Training Program in Arkansas, operated by the Donald W. Reynolds Institute on Aging of the University of Arkansas for Medical Sciences. The Schmieding program trains family caregivers as well as professional caregivers who work in people’s homes or nursing homes.

On the family side, it offers eight hours of instruction in “physical needs” associated with caregiving — managing incontinence, skin care, turning someone regularly in bed, using adaptive equipment, transfers from a bed to a wheelchair, helping patients remain mobile, and more. Classes are offered at five sites and four more are planned in the next several years, said Robin McAtee, associate director of the Reynolds Institute on Aging. If people, churches or senior centers want the instruction, which is free, Schmieding nurses will take the program to them. One-on-one instruction for tasks is also available on request.

A separate eight-hour program is available for caregivers dealing with dementia, who have additional concerns.

At a Web site called Elder Stay at Home, Schmieding sells a package of materials (three DVDs and a booklet, for $99) summarizing the content of its family caregiver training program. Separately, it has begun selling its curriculum for paid caregivers, and programs in California, Hawaii and Texas are among the first buyers. The University of Arkansas for Medical Sciences also has received a $3.7 million innovation grant from the government to expand the caregiver training program more broadly and develop online training materials.

Ms. Reinhard said AARP would like to see Schmieding-style programs rolled out across the country and begin to offer structured, reliable support to caregivers now providing nursing-style care in homes with little or no assistance.

What else am I missing here? Do you know of resources or other organizations providing intensive caregiver training along the lines of what I’ve been discussing? Where would you suggest people turn for this kind of help?

Editor’s Note:

Correction: An earlier version of this post contained an incorrect spelling of the first name of the director of the Families and Health Care Project of the United Hospital Fund. She is Carol Levine, not Carole Levine.

Read More..

In Pursuit of John McAfee, Media Are Part of Story

Late last month, the editor in chief of Vice magazine, Rocco Castoro, joined by a photographer, Robert King, managed to secure a plum exclusive: an invitation to travel along with the fugitive tech millionaire John McAfee.

Years earlier, Mr. McAfee had relocated to a Colonel Kurtz-like compound in the jungles of Belize, surrounding himself with armed guards and multiple young lovers. Then, with reports that he was a “person of interest” in the death of a neighbor, Mr. McAfee had gone on the lam. Last Monday, after several days of surreptitious travel, Mr. Castoro and Mr. King posted their first dispatch. It bore the smirking headline, “We Are With John McAfee Right Now, Suckers.”

The gloating was short-lived, however. Within minutes, a reader noticed that the photograph posted with the story still contained GPS location data embedded by the iPhone 4S that took it, and sent out a message via Twitter: “Check the metadata in the photo. Oooops ...” Vice quickly replaced the image, but it was too late. “Oops! Did Vice Just Give Away John McAfee’s Location With Photo Metadata?” a Wired.com headline asked. The article included a Google Earth view of the exact spot the picture had been taken — poolside at the Hotel & Marina Nana Juana in Izabal, Guatemala.

Soon, the Guatemalan police were with John McAfee. This weekend, he is in their custody and is expected to be extradited to Belize, where he faces questioning in connection with the murder of Gregory Faull, a 52-year-old American who was his neighbor. Mr. McAfee’s lawyers are appealing his extradition.

The Vice debacle was just one colorful twist in the relationship between the press, which is always willing to indulge a colorful subject, and Mr. McAfee, who was always eager to bend news coverage to his often inscrutable ends. I first wrote about Mr. McAfee five years before, when he was merely a colorful software pioneer — an apparently clean-living citizen who courted the press mainly to promote his favorite pastime, flying ultralight aircraft. Since then, his life had taken several darker turns. I had only just published a long piece about his purported connections with Belizean drug gangs on the Web site Gizmodo when I received a curt e-mail from a police official in Belize on Nov. 11, “It may interest you to know that there was a murder yesterday in San Pedro Town, Ambergris Caye and McAfee is the prime suspect.”

I passed the information along on Twitter and on Gizmodo and the news took on a life of its own. “It was on all kinds of Tumblr sites, people were talking about it on Twitter, and that fueled a lot of the professional media to say, ‘O.K., everyone’s talking about this, we should have a story on it, too,’ ” said Mat Honan, a senior writer at Wired who has written about the case.

Mr. McAfee went into hiding with a 20-year-old girlfriend, but it was hiding of a uniquely visible kind. Within 36 hours, he began an aggressive campaign to court and spin coverage of his story. He started by calling Joshua Davis, a Wired writer who had spent the summer reporting on a profile for the magazine’s January issue, and fed him fresh details of life on the run every few hours. Mr. Davis passed along his minute-by-minute updates via Twitter and daily blog posts.

News media around the world were rapt: it wasn’t just that Mr. McAfee’s name was stubbornly familiar, a relic of the early days when computer users installed his software to keep viruses away. “A tech millionaire, an exotic Central American locale, murder, the possibility of drugs — the story just has everything,” says Nathalie Malinarich, world editor of the BBC News Web site.

Wired had a problem, though. The murder and Mr. McAfee’s flight had made Mr. Davis’s print article obsolete before it could even hit newsstands. Wired and Mr. Davis updated the material and repackaged it into an e-book that has sold more than 22,000 copies, at one point reaching No. 1 on the Nonfiction Kindle Singles list.

Mr. Davis’s exclusives did not last long. As the week went on, Mr. McAfee granted phone interviews to more reporters (though none to me, with whom he’s declined to communicate since my first Gizmodo piece). Then he set out to spread his message across new electronic platforms. He started a Twitter account and, with the help of a cartoonist he had befriended in Seattle, a blog. To keep the story fresh, Mr. McAfee kept upping his media exposure and the outrageousness of the tales he told. He arranged face-to-face interviews— a Financial Times journalist first, followed by CNN’s Martin Savidge. (Both were told to wait in public places and then were driven to meet Mr. McAfee in locations unknown to them.) Then, in the ultimate act of bravado, he invited Vice’s journalists to tag along.

For reporters, a McAfee exclusive guaranteed a rich share of readers and viewers and social-networking interest. But many found the favor an ambiguous blessing. Mr. McAfee seemed to understand the dynamics of journalism well enough to know which assertions reporters would pass along without double-checking or qualifying — like his claim that he had eluded the police by burying himself in sand and positioning a box over his head — even as his self-created narrative veered ever further into the surreal.

“As soon as reporters start to think, ‘Wait a minute, we’re sort of jeopardizing our objectivity and reputation for this guy,’ he’ll just burn them, and go to the next one,” says the Gizmodo writer Joel Johnson, who found himself cut off after publishing an article Mr. McAfee did not like. “That’s what he did to me, that’s what he’s done to a lot of journalists, and he’s going to do it to the Vice guys, if he hasn’t done it already.”

Vice seemed to remain in Mr. McAfee’s good graces even after the freedom-endangering gaffe. After the secret of his location spread across the Internet, Mr. McAfee quickly went online to claim that the data leak was in fact an intentional piece of misdirection. Mr. King, the Vice photographer, supported the claim on social media. This amounted to following up an “egregiously stupid action with a far worse one,” Mr. Honan wrote in a Wired post later last week, “King apparently lied on his Facebook page and Twitter in order to protect McAfee.”

In a statement, Vice said it would not comment about its reporting in the McAfee case.

“The flight we chronicled was from the start filled with misinformation, rumors, social-media-fed myths, outright lies and overall total weirdness,” the magazine said. “Despite many media outlets’ obvious glee in damning us immediately, Vice has decided to wait and talk to the people on our team who were actually on the ground and who could therefore tell us what actually went down and not just buy into the same rumors, myths and madness that this story has consisted of from the start.”

Indeed, while Mr. McAfee seems determined to drag out his drama as long as he can, some of the journalists who have covered him say they have had enough. “People try to behave ethically,” said Mr. Johnson, who wrote his final post on Mr. McAfee three weeks ago. “And he milks that out of them until they get to the point where they’re like, ‘You know what, you’re just nuts.’ ” He adds, “I know as a journalist I can’t say that, so I’ve got to get out of this story.”

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Iran Has Rosy View of Unrest in Syria

TEHRAN — When Syria’s agricultural minister, Subhi Ahmad al-Abdullah, arrived in the Iranian capital for a visit last week, everybody involved stuck to a well-worn script.

There were welcoming ceremonies, handshakes in front of cameras and tête-à-têtes on rococo chairs. Stern-faced Iranian and Syrian officials discussed “expanding economic and agricultural ties” and signed a contract for the joint production of a vaccine for foot-and-mouth disease.

The unrest in Syria did not go unmentioned in the meetings, which were widely reported by Iranian state media. Iran’s vice president, Mohammad-Reza Rahimi, said Iran was confident of victory for the Syrian government forces, who, he said, were engaged in “sporadic fights with terrorists sent by regional countries.”

The upbeat ceremonies surrounding Mr. Abdullah’s visit illustrate how Iranian leaders perceive the bloody conflict that has engulfed their main ally in the Arabic world. While former Iranian diplomats, academics and analysts increasingly warn that President Bashar al-Assad’s government is on the brink of collapse, the country’s highest leaders insist the conflict is manageable and ultimately will be resolved to Iran’s advantage.

“We say that Bashar al-Assad, or at least his government, is the safest bet for stability and security in Syria,” said Amir Mohebbian, a political analyst whose views are sometimes published on the Web site of Iran’s supreme leader, Ayatollah Ali Khamenei. “If the foreign mercenaries take over, there will be a blood bath in Syria.”

Endless news broadcasts by Iran’s state television offer an ideological narrative in which Saudi Arabia and Qatar are doing the bidding of the United States and Israel, helping to arm foreign “terrorists” and sending them into Syria to punish it for having opposed Israel. War crimes committed by Syrian forces go unreported.

“Clearly, there is no real alternative for al-Assad and his government in Syria,” Mr. Mohebbian said. “They have agreed to reforms; there will be a multiparty system in Syria. So foreign countries should stop arming terrorists and let the Syrian people decide their own future.”

Some former diplomats, analysts and academics disagree with the blind support of Syria’s government. But they have little, if any, influence on Iran’s policy makers, who are mostly rigid ideologues.

“The Syrian Army is on the brink of complete collapse, and the downfall of al-Assad is inevitable,” Ebrahim Yazdi, a former foreign minister who is a member of the opposition, wrote Saturday in the newspaper Etemaad, which is critical of Iran’s government. “Syria’s leaders respond to reforms with bloody crackdowns. Their future is very bleak.”

Mashallah Shamsolvaezin, a Middle East analyst who has been imprisoned for his involvement in Iran’s opposition movement, echoed that view. “In reality, Syria will be in turmoil for years to come,” he said. “There will be nothing left of our anti-Israel front.”

Iran has organized two conferences for what it calls the “genuine” Syrian opposition, pushing for modest political changes, followed by nationwide presidential elections in 2014, as the only solution to stop the fighting.

Off the record, Iranian officials sometimes hint that Mr. Assad, as a symbol, could be sacrificed in Iran’s future vision for the country. But they insist that his political and security apparatus should remain in power, continuing to lead Syria as a regional spear against Iran’s archnemesis, Israel.

“We are seeking a peaceful solution in which the Syrian government implements reforms,” said Hamidreza Taraghi, a politician who is close to Iran’s leaders. “But whatever the cost, we want to keep Syria in the group of resistance against Israel.”

Mr. Taraghi, who recently led an Iranian delegation to North Korea and met with the country’s leader, Kim Jong-un, said that Iran was willing to do “whatever it takes” to keep Syria as an ally. He said the Syrian government had not yet asked Iran for military help, but if that happened Iran would be compelled by its treaty with Syria to step in.

Ramtin Rastin contributed reporting.

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Changes to Agriculture Highlight Cuba’s Problems

HAVANA — Cuba’s liveliest experiment with capitalism unfolds every night in a dirt lot on the edge of the capital, where Truman-era trucks lugging fresh produce meet up with hundreds of buyers on creaking bicycle carts clutching wads of cash.

“This place, it feeds all of Havana,” said Misael Toledo, 37, who owns three small food stores in the city. “Before, you could only buy or sell in the markets of Fidel.”

The agriculture exchange, which sprang up last year after the Cuban government legalized a broader range of small businesses, is a vivid sign of both how much the country has changed, and of all the political and practical limitations that continue to hold it back.

President Raúl Castro has made agriculture priority No. 1 in his attempt to remake the country. He used his first major presidential address in 2007 to zero in on farming, describing weeds conquering fallow fields and the need to ensure that “anyone who wants can drink a glass of milk.”

No other industry has seen as much liberalization, with a steady rollout of incentives for farmers. And Mr. Castro has been explicit about his reasoning: increasing efficiency and food production to replace imports that cost Cuba hundreds of millions of dollars a year is a matter “of national security.”

Yet at this point, by most measures, the project has failed. Because of waste, poor management, policy constraints, transportation limits, theft and other problems, overall efficiency has dropped: many Cubans are actually seeing less food at private markets. That is the case despite an increase in the number of farmers and production gains for certain items. A recent study from the University of Havana showed that market prices jumped by nearly 20 percent in 2011 alone. And food imports increased to an estimated $1.7 billion last year, up from $1.4 billion in 2006.

“It’s the first instance of Cuba’s leader not being able to get done what he said he would,” said Jorge I. Domínguez, vice provost for international affairs at Harvard, who left Cuba as a boy. “The published statistical results are really very discouraging.”

A major cause: poor transportation, as trucks are in short supply, and the aging ones that exist often break down.

In 2009, hundreds of tons of tomatoes, part of a bumper crop that year, rotted because of a lack of transportation by the government agency charged with bringing food to processing centers.

“It’s worse when it rains,” said Javier González, 27, a farmer in Artemisa Province who described often seeing crops wilt and rot because they were not picked up.

Behind him were the 33 fertile, rent-free acres he had been granted as part of a program Mr. Castro introduced in 2008 to encourage rural residents to work the land. After clearing it himself and planting a variety of crops, Mr. Gonzalez said, he was doing relatively well and earned more last year than his father, who is a doctor, did.

But Cuba’s inefficiencies gnawed at him. Smart, strong, and ambitious, he had expansion plans in mind, even as in his hand he held a wrench. He was repairing a tractor part meant to be grading land. It was broken. Again.

The 1980s Soviet model tractor he bought from another farmer was as about good as it gets in Cuba. The Cuban government maintains a monopoly on selling anything new, and there simply is not enough of anything — fertilizer, or sometimes even machetes — to go around.

Government economists are aware of the problem. “If you give people land and no resources, it doesn’t matter what happens on the land,” said Joaquin Infante of the Havana-based Cuban National Association of Economists.

But Mr. Castro has refused to allow what many farmers and experts see as an obvious solution to the shortages of transportation and equipment: Let people import supplies on their own. “It’s about control,” said Philip Peters, a Cuba analyst with the Lexington Institute, a Virginia-based research group.

Other analysts agree, noting that though the agricultural reforms have gone farther than other changes — like those that allow for self-employment — they remain constrained by politics.

“The government is not ready to let go,” said Ted Henken, a Latin American studies professor at Baruch College. “They are sending the message that they want to let go, or are trying to let go, but what they have is still a mechanism of control.”

For many farmers, that explains why land leases last for 10 years with a chance to renew, not indefinitely or the 99 years offered to foreign developers. It is also why many farmers say they will not build homes on the land they lease, despite a concession this year to allow doing so.

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New Taxes to Take Effect to Fund Health Care Law

WASHINGTON — For more than a year, politicians have been fighting over whether to raise taxes on high-income people. They rarely mention that affluent Americans will soon be hit with new taxes adopted as part of the 2010 health care law.

The new levies, which take effect in January, include an increase in the payroll tax on wages and a tax on investment income, including interest, dividends and capital gains. The Obama administration proposed rules to enforce both last week.

Affluent people are much more likely than low-income people to have health insurance, and now they will, in effect, help pay for coverage for many lower-income families. Among the most affluent fifth of households, those affected will see tax increases averaging $6,000 next year, economists estimate.

To help finance Medicare, employees and employers each now pay a hospital insurance tax equal to 1.45 percent on all wages. Starting in January, the health care law will require workers to pay an additional tax equal to 0.9 percent of any wages over $200,000 for single taxpayers and $250,000 for married couples filing jointly.

The new taxes on wages and investment income are expected to raise $318 billion over 10 years, or about half of all the new revenue collected under the health care law.

Ruth M. Wimer, a tax lawyer at McDermott Will & Emery, said the taxes came with “a shockingly inequitable marriage penalty.” If a single man and a single woman each earn $200,000, she said, neither would owe any additional Medicare payroll tax. But, she said, if they are married, they would owe $1,350. The extra tax is 0.9 percent of their earnings over the $250,000 threshold.

Since the creation of Social Security in the 1930s, payroll taxes have been levied on the wages of each worker as an individual. The new Medicare payroll is different. It will be imposed on the combined earnings of a married couple.

Employers are required to withhold Social Security and Medicare payroll taxes from wages paid to employees. But employers do not necessarily know how much a worker’s spouse earns and may not withhold enough to cover a couple’s Medicare tax liability. Indeed, the new rules say employers may disregard a spouse’s earnings in calculating how much to withhold.

Workers may thus owe more than the amounts withheld by their employers and may have to make up the difference when they file tax returns in April 2014. If they expect to owe additional tax, the government says, they should make estimated tax payments, starting in April 2013, or ask their employers to increase the amount withheld from each paycheck.

In the Affordable Care Act, the new tax on investment income is called an “unearned income Medicare contribution.” However, the law does not provide for the money to be deposited in a specific trust fund. It is added to the government’s general tax revenues and can be used for education, law enforcement, farm subsidies or other purposes.

Donald B. Marron Jr., the director of the Tax Policy Center, a joint venture of the Urban Institute and the Brookings Institution, said the burden of this tax would be borne by the most affluent taxpayers, with about 85 percent of the revenue coming from 1 percent of taxpayers. By contrast, the biggest potential beneficiaries of the law include people with modest incomes who will receive Medicaid coverage or federal subsidies to buy private insurance.

Wealthy people and their tax advisers are already looking for ways to minimize the impact of the investment tax — for example, by selling stocks and bonds this year to avoid the higher tax rates in 2013.

The new 3.8 percent tax applies to the net investment income of certain high-income taxpayers, those with modified adjusted gross incomes above $200,000 for single taxpayers and $250,000 for couples filing jointly.

David J. Kautter, the director of the Kogod Tax Center at American University, offered this example. In 2013, John earns $160,000, and his wife, Jane, earns $200,000. They have some investments, earn $5,000 in dividends and sell some long-held stock for a gain of $40,000, so their investment income is $45,000. They owe 3.8 percent of that amount, or $1,710, in the new investment tax. And they owe $990 in additional payroll tax.

The new tax on unearned income would come on top of other tax increases that might occur automatically next year if President Obama and Congress cannot reach an agreement in talks on the federal deficit and debt. If Congress does nothing, the tax rate on long-term capital gains, now 15 percent, will rise to 20 percent in January. Dividends will be treated as ordinary income and taxed at a maximum rate of 39.6 percent, up from the current 15 percent rate for most dividends.

Under another provision of the health care law, consumers may find it more difficult to obtain a tax break for medical expenses.

Taxpayers now can take an itemized deduction for unreimbursed medical expenses, to the extent that they exceed 7.5 percent of adjusted gross income. The health care law will increase the threshold for most taxpayers to 10 percent next year. The increase is delayed to 2017 for people 65 and older.

In addition, workers face a new $2,500 limit on the amount they can contribute to flexible spending accounts used to pay medical expenses. Such accounts can benefit workers by allowing them to pay out-of-pocket expenses with pretax money.

Taken together, this provision and the change in the medical expense deduction are expected to raise more than $40 billion of revenue over 10 years.

Read More..

New Taxes to Take Effect to Fund Health Care Law

WASHINGTON — For more than a year, politicians have been fighting over whether to raise taxes on high-income people. They rarely mention that affluent Americans will soon be hit with new taxes adopted as part of the 2010 health care law.

The new levies, which take effect in January, include an increase in the payroll tax on wages and a tax on investment income, including interest, dividends and capital gains. The Obama administration proposed rules to enforce both last week.

Affluent people are much more likely than low-income people to have health insurance, and now they will, in effect, help pay for coverage for many lower-income families. Among the most affluent fifth of households, those affected will see tax increases averaging $6,000 next year, economists estimate.

To help finance Medicare, employees and employers each now pay a hospital insurance tax equal to 1.45 percent on all wages. Starting in January, the health care law will require workers to pay an additional tax equal to 0.9 percent of any wages over $200,000 for single taxpayers and $250,000 for married couples filing jointly.

The new taxes on wages and investment income are expected to raise $318 billion over 10 years, or about half of all the new revenue collected under the health care law.

Ruth M. Wimer, a tax lawyer at McDermott Will & Emery, said the taxes came with “a shockingly inequitable marriage penalty.” If a single man and a single woman each earn $200,000, she said, neither would owe any additional Medicare payroll tax. But, she said, if they are married, they would owe $1,350. The extra tax is 0.9 percent of their earnings over the $250,000 threshold.

Since the creation of Social Security in the 1930s, payroll taxes have been levied on the wages of each worker as an individual. The new Medicare payroll is different. It will be imposed on the combined earnings of a married couple.

Employers are required to withhold Social Security and Medicare payroll taxes from wages paid to employees. But employers do not necessarily know how much a worker’s spouse earns and may not withhold enough to cover a couple’s Medicare tax liability. Indeed, the new rules say employers may disregard a spouse’s earnings in calculating how much to withhold.

Workers may thus owe more than the amounts withheld by their employers and may have to make up the difference when they file tax returns in April 2014. If they expect to owe additional tax, the government says, they should make estimated tax payments, starting in April 2013, or ask their employers to increase the amount withheld from each paycheck.

In the Affordable Care Act, the new tax on investment income is called an “unearned income Medicare contribution.” However, the law does not provide for the money to be deposited in a specific trust fund. It is added to the government’s general tax revenues and can be used for education, law enforcement, farm subsidies or other purposes.

Donald B. Marron Jr., the director of the Tax Policy Center, a joint venture of the Urban Institute and the Brookings Institution, said the burden of this tax would be borne by the most affluent taxpayers, with about 85 percent of the revenue coming from 1 percent of taxpayers. By contrast, the biggest potential beneficiaries of the law include people with modest incomes who will receive Medicaid coverage or federal subsidies to buy private insurance.

Wealthy people and their tax advisers are already looking for ways to minimize the impact of the investment tax — for example, by selling stocks and bonds this year to avoid the higher tax rates in 2013.

The new 3.8 percent tax applies to the net investment income of certain high-income taxpayers, those with modified adjusted gross incomes above $200,000 for single taxpayers and $250,000 for couples filing jointly.

David J. Kautter, the director of the Kogod Tax Center at American University, offered this example. In 2013, John earns $160,000, and his wife, Jane, earns $200,000. They have some investments, earn $5,000 in dividends and sell some long-held stock for a gain of $40,000, so their investment income is $45,000. They owe 3.8 percent of that amount, or $1,710, in the new investment tax. And they owe $990 in additional payroll tax.

The new tax on unearned income would come on top of other tax increases that might occur automatically next year if President Obama and Congress cannot reach an agreement in talks on the federal deficit and debt. If Congress does nothing, the tax rate on long-term capital gains, now 15 percent, will rise to 20 percent in January. Dividends will be treated as ordinary income and taxed at a maximum rate of 39.6 percent, up from the current 15 percent rate for most dividends.

Under another provision of the health care law, consumers may find it more difficult to obtain a tax break for medical expenses.

Taxpayers now can take an itemized deduction for unreimbursed medical expenses, to the extent that they exceed 7.5 percent of adjusted gross income. The health care law will increase the threshold for most taxpayers to 10 percent next year. The increase is delayed to 2017 for people 65 and older.

In addition, workers face a new $2,500 limit on the amount they can contribute to flexible spending accounts used to pay medical expenses. Such accounts can benefit workers by allowing them to pay out-of-pocket expenses with pretax money.

Taken together, this provision and the change in the medical expense deduction are expected to raise more than $40 billion of revenue over 10 years.

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You for Sale: Company Envisions ‘Vaults’ for Personal Data

Peter DaSilva for The New York Times

Michael Fertik, the founder and chief executive of Reputation.com, at its offices in Redwood City, Calif., where he has amassed a database of information collected on millions of consumers.

“YOU are walking around naked on the Internet and you need some clothes,” says Michael Fertik. “I am going to sell you some.”

Naked? Not exactly, but close.

Mr. Fertik, 34, is the chief executive of Reputation.com, a company that helps people manage their online reputations. From his perch here in Silicon Valley, he views the digital screens in our lives, the smartphones and the tablets, the desktops and the laptops, as windows of a house. People go about their lives on the inside, he says, while dozens of marketing and analytics companies watch through the windows, sizing them up like peeping Toms.

By now many Americans are learning that they are living in a surveillance economy. “Information resellers,” also known as “data brokers,” have collected hundreds to thousands of details — what we buy, our race or ethnicity, our finances and health concerns, our Web activities and social networks — on almost every American adult. Other companies that specialize in ranking consumers use computer algorithms to covertly score Internet users, identifying some as “high-value” consumers worthy of receiving pitches for premium credit cards and other offers, while dismissing others as a waste of time and marketing money. Yet another type of company, called an ad-trading platform, profiles Internet users and auctions off online access to them to marketers in a practice called “real-time bidding.”

As these practices have come to light, several members of Congress, and federal agencies, have opened investigations.

At least for now, however, these companies typically do not permit consumers to see the records or marketing scores that have been compiled about them. And that is perfectly legal.

Now, Mr. Fertik, the loquacious, lion-maned founder of Reputation.com, says he has the free-market solution. He calls it a “data vault,” or “a bank for other people’s data.”

Here at Reputation.com’s headquarters, a vast open-plan office decorated with industrial-looking metal struts and reclaimed wood — a discreet homage to the lab where Thomas Edison invented the light bulb — his company has amassed a database on millions of consumers. Mr. Fertik plans to use it to sell people on the idea of taking control of their own marketing profiles. To succeed, he will have to persuade people that they must take charge of their digital personas.

Pointing out the potential hazards posed by data brokers and the like is part of Mr. Fertik’s M.O. Covert online profiling and scoring, he says, may unfairly exclude certain Internet users from marketing offers that could affect their financial, educational or health opportunities — a practice Mr. Fertik calls “Weblining.” He plans to market Reputation.com’s data vault, scheduled to open for business early next year, as an antidote.

“A data privacy vault,” he says, “is a way to control yourself as a person.”

Reputation.com is at the forefront of a nascent industry called “personal identity management.” The company’s business model for its vault service involves collecting data about consumers’ marketing preferences and giving them the option to share the information on a limited basis with certain companies in exchange for coupons, say, or status upgrades. In turn, participating companies will get access both to potential customers who welcome their pitches and to details about the exact products and services those people are seeking. In theory, the data vault would earn money as a kind of authorization supervisor, managing the permissions that marketers would need to access information about Reputation.com’s clients.

To some, the idea seems a bit quixotic.

Reputation.com, with $67 million in venture capital, is not making a profit. Although the company’s “privacy” products, like removing clients’ personal information from list broker and marketing databases, are popular, its reputation management techniques can be controversial. For instance, it offers services meant to make negative commentary about individual or corporate clients less visible on the Web.

And there are other hurdles, like competition. A few companies, like Personal, have already introduced vault services. Also, a number of other enterprises have tried — and quickly failed — to sell consumers on data lockers.

Even so, Mr. Fertik contends Reputation.com has the answer. The company already has several hundred thousand paying customers, he says, and patents on software that can identify consumers’ information online and score their reputations. He intends to show clients their scores and advise them on how to improve them.

“You can’t just build a vault and wish that vendors cared enough about your data to pay for it,” Mr. Fertik says. “You have to build a business that gives you the lift to accumulate a data set and attract consumers, the science to create insights that are valuable to vendors, and the power to impose restrictions on the companies who consume your data.”

THE consumer data trade is large and largely unregulated.

Companies and organizations in the United States spend more than $2 billion a year on third-party data about individuals, according to a report last year on personal identity management from Forrester Research, a market research firm. They spend billions more on credit data, market research and customer data analytics, the report said.

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Stalled Adoption Program in Guatemala Leaves Families in Limbo

Rodrigo Cruz for The New York Times

Amy and Rob Carr in Guatemala with Geovany Archilla Rodas, whom they have been trying to adopt since 2007. More Photos »

GUATEMALA CITY — The little boy flies like an airplane through the hotel, his arms outstretched. Then he leaps like a superhero, beaming as the red lights on his new sneakers flash and flicker, while the American couple he is with dissolve in laughter.

He calls them Mamá and Papi. They call him Hijo — Son. He corrects their fledgling Spanish. They teach him English. “Awe-some,” he repeats carefully, eyeing his new shoes.

To outsiders, they look like a family. But Geovany Archilla Rodas, an impish 6-year-old boy with spiky black hair, lives in an orphanage on the outskirts of this capital city. The Americans — Amy and Rob Carr of Reno, Nev. — live a world away. They are the only parents he has ever known.

They have been visiting him every year, usually twice a year, since he was a toddler, flying into this Central American city for a few days at a time to buy him clothes and to read him stories, to wipe his tears and to tickle him until he collapses in giggles at their hotel or in the orphanage.

Yet half a decade after agreeing to adopt him, the Carrs still have no idea when — or if — they will ever take Geovany home.

“There’s this hope in you that doesn’t want to die,” said Mrs. Carr, who arrived here last month with her husband, more determined than ever to cut through the bureaucracy. “In my heart, he’s my son.”

The Carrs are among the 4,000 Americans who found themselves stuck in limbo when Guatemala shut down its international adoption program in January 2008 amid mounting evidence of corruption and child trafficking. Officials here and in Washington promised at the time to process the remaining cases expeditiously.

But officials and prospective parents say that bureaucratic delays, lengthy investigations and casework hobbled by shortages of staff and resources have left hundreds of children stranded in institutions for years. Today, 150 children — including Geovany — are still waiting in orphanages and foster homes here while the Guatemalan authorities weigh whether to approve their adoptions to families in the United States.

Stalled adoptions are not unique to Guatemala. Concerns about fraud, including allegations of kidnappings and baby selling, have held up American adoptions for months, and sometimes years, from Ethiopia, Kyrgyzstan, Vietnam and Haiti. The State Department currently refuses to approve adoptions from Cambodia and Vietnam to pressure those countries to install safeguards so that children with biological relatives who can care for them are not shipped overseas, officials say.

But the problem of delayed adoptions is particularly acute in Guatemala, a country of about 14 million people, which in 2007 ranked second only to China in the number of children sent to the United States.

As officials here have spent months, and then years, trying to distinguish legitimate adoptions from fraudulent ones, many hopeful couples who had painted nurseries, hosted baby showers and bought brand new cribs began to despair as the infants they had hoped to adopt took their first steps and spoke their first words without them.

Faced with a seemingly endless process, scores of prospective parents quietly abandoned their efforts to adopt the children they once considered their own, officials say.

Guatemalan officials said they never intended for the children to remain institutionalized for so long. They say they have had to thoroughly investigate the cases, some of which are complicated by inconsistencies, false documents and questionable stories, to ensure that the children were not bought or stolen from impoverished rural women.

“These are very vulnerable people, who can be easily taken advantage of,” said Elizabeth Orrego de Llerena, president of the board of directors of the National Adoption Council, which is processing the adoption cases once they have been cleared by the child welfare investigative branch. “At times, they have not had the opportunity to make a complaint or to seek solutions.”

Ms. Orrego de Llerena said that the investigations, which typically include searches for biological relatives, were necessary to ensure that children were given up voluntarily.

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Art and Commerce Meet in Miami Beach

Katie Orlinsky for The New York Times

Visitors at the V.I.P. opening of Art Basel Miami Beach.

MIAMI — Mera Rubell was taking time out from greeting the hundreds of visitors at her family’s sprawling contemporary art center here to vent.

“It’s the height of arrogance to dismiss — — ,” she began.

Jason, her son, interrupted: “It’s arrogance. It’s a completely uninteresting story.”

For the moment her husband, Don, had given up on trying to get a word in.

The Rubells, deans of Miami’s bustling art scene, were pushing back against a chorus of complaints that has been growing louder in the weeks leading up to Art Basel Miami Beach, the annual art pilgrimage that began Wednesday and ends Sunday.

Prominent art writers and critics, including Sarah Thornton, Felix Salmon, Will Gompertz and Dave Hickey, have been attacking the art world, arguing that the staggering sums of money being spent on works are distorting judgments about art and undermining its long-term cultural significance.

“Money talks loudly and easily drowns out other meanings,” Ms. Thornton wrote in TAR magazine in a recent article, “Top 10 Reasons NOT to Write About the Art Market.”

In its special edition for the opening day of the fair, The Art Newspaper asked whether “the art world is facing a crisis of values” because of the “pernicious influence of the market on art.”

And in the eyes of many critics, Art Basel Miami Beach — or what Simon Doonan, writing in Slate last week, labeled a “promo-party cheese-fest” — has become a symbol of everything that’s wrong with the art market. The fair’s extraordinary success in just over a decade, and its celebration of wretched excess, have triggered a backlash.

But the Rubells, along with a growing number of other prominent collectors, art dealers and curators, are having none of it. The backlash against the backlash has begun.

“The market supports artists,” Jason Rubell said. Given the limited amount of government support for the arts, he added, “it’s an industry that without commerce doesn’t exist. What do people want — to go back to the recession?”

Ms. Rubell was annoyed that critics seemed to ignore the social, economic and cultural transformation of Miami that the fair and collectors like her have helped bring about. She noted that the Rubells’ 45,000-square-foot art center — where one huge gallery is now filled with works by Oscar Murillo, a 26-year-old Colombian immigrant who lived with and was supported by the Rubells while he created dozens of mural-sized canvases — used to be a Drug Enforcement Administration storage center.

Outside, in the center’s courtyard, visitors like Martha Stewart admired the French artist Bernar Venet’s collaboration with Bugatti, the superluxury sports car brand, on a one-of-a-kind Veyron Grand Sport Venet car (a price hasn’t been set, a Bugatti spokeswoman said, but will undoubtedly be in “the higher end of the millions”).

“I’m grateful to Bugatti, Perrier, Bank of America and other companies,” Ms. Rubell declared. “Their support helps facilitate quality programs and opens exhibits like this” — the Murillo show — “to the public.”

In Miami Beach, at the main fair, the consumer-oriented glitter abounds this week: coffee carts with $20-a-glass Ruinart Champagne; Davidoff cigar rollers; BMW’s artist-designed cars; and Takashi Murakami’s $70,000-and-up commissioned portraits. One could almost imagine that the Barbara Kruger work on display at L&M gallery — a super-sized sign reading “Greedy” on one line and an unprintable expletive on the next — had an invisible subtitle telling the wealthy V.I.P.’s who had come to shop, “I’m Talking to You — Yeah, You!”

Of course, rich patrons have always supported artists, Don Rubell pointed out, from the pharaohs to the Medicis. Today, multimillion-dollar sales represent only a silk-thin layer of a deeply varied and thriving art market. The art world, Mr. Rubell asserted, is “actually becoming more democratic.”

“There’s 20 ancillary fairs” in addition to the high-end main event of Art Basel, he said. “Whatever amount of money you have in your pocket, you can enter this magical world of art.”

The notion that the art market contains multitudes is one with which Marc Glimcher, part of the family dynasty that runs the Pace Gallery, said he agreed.

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