Your Money: Walking the Tightrope on Mental Health Coverage

Insurance covers more mental health care than many people may realize, and more people will soon have the kind of health insurance that does so. But coverage goes only so far when there aren’t enough practitioners who accept it — or there aren’t any nearby, or they aren’t taking any new patients.

In the days after the Newtown, Conn., school shooting, parents and politicians took to the airwaves to make broad-based proclamations about the sorry state of mental health care in America. But a closer look reveals a more nuanced view, with a great deal of recent legislative progress as well as plenty of infuriating coverage gaps.

The stakes in any census of mental health insurance coverage are high given how many people are suffering. Twenty-six percent of adults experience a diagnosable mental disorder in any given year, and 6 percent of all adults experience a seriously debilitating mental illness, according to the National Institute of Mental Health. Twenty-one percent of teenagers experience a severe emotional disturbance between the ages of 13 and 18.

According to this year’s Society for Human Resource Management survey of 550 employers of all sizes, including nonprofits and government entities, 85 percent offer at least some mental health insurance coverage. A 2009 Mercer survey found that 84 percent of employers with more than 500 employees covered both in-network and out-of-network mental health and substance abuse treatments.

For now, some people who have no health insurance or who buy it on their own may avoid purchasing mental health coverage too, or may avoid seeking treatment for things like addiction or depression. This happens for many of the same reasons that there has historically been less mental health coverage than there has been for other illnesses. The earliest objections among insurance providers and employers had to do with whether mental disorders existed at all, according to Howard Goldman, a professor of psychiatry at the University of Maryland school of medicine. Then there were questions about whether treatment actually worked. Next, concerns arose over cost and how often people would avail themselves of costly mental health treatments.

But a subset of adults who have good insurance coverage still avoid treatment for mental illness to this day, according to Edward A. Kaplan, senior vice president and national practice leader for the Segal Company, a benefits consultant that works with many unions. “Culturally, a lot of people driving trucks don’t believe in it and suffer through,” he said. “And a lot of transport unions don’t trust employers and think they will look at it and use it to retaliate against the workers.”

For many of the people who do have mental health coverage, there is now a bit more of it at a lower cost than there might have been five years ago, even if mental health insurance over all remains much less generous than it was many years ago when employees did not pay as much out of pocket. That’s because a 2008 federal law requires employers with more than 50 employees that do offer mental health coverage to have no more restrictions than there are for physical injuries or surgery, and no higher costs.

This so-called parity bill now applies to a crucial provision of President Obama’s Affordable Care Act. Insurance plans in the exchanges that will offer health coverage to millions of uninsured individuals starting in 2014 must cover many items and services, including mental health disorders and substance abuse.

The combination of parity and expanded care is crucial, according to Anthony Wright, the executive director of Health Access, a consumer advocacy organization in California. After all, parity doesn’t do much good if the mental health coverage need only be equivalent to a meager health insurance plan that covers very little.

Then again, what good is parity in mental health insurance if you can’t get the treatment you need? Plenty of psychiatrists in private practice accept no insurance at all, though it is not clear how many; their professional organizations claim to have no recent or decent data on the percentage of people in private practice who take cash on the barrelhead, write people a receipt and send them off to their insurance company to request out-of-network reimbursement if they have any at all.

According to a 2008 American Psychological Association survey, 85 percent of the 2,200 respondents who said they worked at least part time in private practice received at least some third-party payments for their services. That doesn’t mean they take your insurance, though.

Nor does it guarantee that they or other mental health practitioners are anywhere near you or have any imminent openings for appointments. This can be a challenge for people who live far from major cities or big medical centers and need treatment for mental illnesses like severe depression or schizophrenia or disorders like autism.

But it is a particular problem for parents of autistic children who need specialized treatment that is relatively new or that not many people are trained to do. Amanda Griffiths, who lives in Carlisle, Pa., and is the mother of two autistic boys, called 17 providers within two hours of her home before finding one who was qualified to evaluate her younger son and was accepting new patients his age.

“No amount of insurance is going to magically make a provider appear,” she said.

And it remains a struggle to persuade insurance companies and employers to cover treatment that is new or expensive, even if it’s likely to be effective. Ira Burnim, legal director of the Bazelon Center for Mental Health Law, points to something called assertive community treatment, a team-based approach that has proved useful for adults with severe mental illness and holds promise for children, too. There, the challenge is to define what kinds of interaction with a patient outside of an office setting is billable and write rules for coverage.

Autistic children can benefit from an intensive treatment called applied behavior analysis, but many insurance companies haven’t wanted to cover what can be a $60,000 or $70,000 annual cost. They claim that the treatment, which can include intensive one-on-one interaction and assistance with both basic and more complex skills, is either too experimental or an educational service that schools should provide. This can be a tricky area for parents to navigate, because it isn’t always clear which part of an overall health insurance policy ought to cover various possible treatments.

A law school professor named Lorri Unumb faced a bill that big several years ago when her son Ryan was found to be autistic and she discovered that her insurance would not pay for treatment. After moving to South Carolina and meeting families there who had not been able to afford the therapy, she spent two years persuading state legislators to pass a law that forced insurance companies to pay for the treatment. “I did not really know how to write a bill,” she said. “I had watched ‘Schoolhouse Rock’ before, and that was kind of my inspiration and guidance.”

Autism Speaks, a national advocacy organization, saw what she accomplished and hired her to barnstorm the country in an effort to get similar laws passed. There are now 32 states that have them, though there’s a crucial catch: they don’t apply to the many large employers who pool their own resources in so-called self-funded insurance plans.

If you work in such a company, it may be up to you to lobby your human resources department to cover applied behavioral analysis or whatever mental health therapy you or your child may need. Sometimes a personal appeal will succeed; Mr. Kaplan, the benefits consultant, noted that when a parent called about a child, an employer might be particularly sensitive.

But a part of Ms. Unumb’s job these days is to assist parents with appeals where employers have said no or appear likely to. She has accompanied parents to meetings with their human resources departments all over the country to request that the employer expand coverage for everyone. She has a 115-page presentation that she draws on, pointing out that at its core, autism is a medical condition diagnosed by a doctor, the very thing health insurance is supposed to cover.

At $60,000 or more annually for children with particularly acute treatment needs, the coverage does not come cheaply. But Autism Speaks estimates that that expense, spread over thousands of employees, raises premium costs 31 cents a month.

Ms. Unumb notes that for many autistic children, intensive early intervention can allow them to function in mainstream classrooms and prevent a host of problems there and once they finish school. “You pay for it now or you pay for it later,” she said. “And you pay for it a lot more if you choose later, in more ways than just financial.”

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High & Low Finance: In Japan, a Test of Inflation Targets

“Under a paper-money system, a determined government can always generate higher spending and, hence, positive inflation.”

— Ben Bernanke, 2002

Now we may find out if Mr. Bernanke was right. Japan appears to be ready to do whatever it takes to end its long run of falling prices. The Bank of Japan took limited action on Thursday, and more is expected in the new year.

Mr. Bernanke, then a member of the Board of Governors of the Federal Reserve, and now its chairman, gave the speech quoted above at a time when the American economy was stumbling along in a slow recovery and prices, at least as measured by the Consumer Price Index, were declining.

He was arguing that the Fed would not be out of ammunition if it cut nominal interest rates to zero and the economy failed to respond. He has since proved he was right about that. In the speech, he made a passing reference to a phrase used by Milton Friedman, about using a “helicopter drop” of money to fight inflation, which eventually earned him the nickname “Helicopter Ben” from conservatives scandalized by his aggressive action after the financial crisis began.

For two decades, Japan has provided stark evidence that chronic deflation is possible in a modern economy. Prices have fallen steadily despite extraordinarily low interest rates. The economy has stagnated.

This week the Liberal Democratic Party, which had ruled Japan for nearly its entire postwar history until it was swept from power three years ago, won a landslide victory. Shinzo Abe, the prime minister from 2006 to 2007, will get another chance.

Mr. Abe devoted a decent part of his campaign to criticism of the Bank of Japan, the country’s central bank. He wants the bank to pursue inflation, and to effectively print money until it gets it. At one point during the campaign he spoke of a 3 percent inflation target, although he seems to have cut that back to 2 percent.

Either goal, if realized, would be a major change for the country. The inflation index used in calculations of gross domestic product is now 18 percent lower than it was at the end of 1994.

On Thursday, the central bank took a relatively small step in the direction favored by Mr. Abe. It decided to step up its asset purchases and seemed to leave open the possibility that it would adopt the inflation target at a later meeting. Mr. Abe praised the move.

To a significant extent, deflationary expectations are now baked into the Japanese economy. Tiny government bond yields have persisted for many years. Even though the nominal yields are small, the real (after inflation) yields have been respectable because there has been deflation, not inflation. And the competition has not been that great. The stock market has fluctuated, but it remains far below where it was when the Japanese bubble began to deflate in the early 1990s. Real estate losses from that bubble — do you remember when the gardens of the Imperial Palace in Tokyo were supposed to be worth more than the entire state of California? — still have an impact on investor psychology.

Western economists, Mr. Bernanke among them, have long called for Japan to target inflation. Lately, some Chinese economists have been offering similar lectures. But until now, little has happened. The central bank has announced a goal of positive inflation of up to 1 percent, but it is not widely believed, and it has certainly not happened.

As it is, the limited quantitative easing efforts of the Japanese central bank have been viewed as temporary, and as not really changing anything. Whether the new promises of something more significant will be credible remains to be seen.

“At this point, moving to a 2 percent target would not be such a giant step,” said Kenneth Rogoff, a Harvard economist who has suggested inflation targeting in the United States as well as in Japan. “They have to pursue it vigorously until we have inflation expectations firmly higher. No one knows how much they would have to do to accomplish that.”

The Bank of Japan has in the past been hesitant to really try to establish that credibility, for at least two reasons. One is that there is fear that the Japanese government bond market would be disrupted. Another is that it could do severe damage to the central bank’s own balance sheet. It owns a lot of Japanese government bonds whose market value would fall. Conceivably, that could cause the bank to seek a recapitalization from the government, something that would be embarrassing, to say the least.

To establish the credibility, the central bank would have to show a readiness to create credit at a rapid rate. It would probably also need to take steps to hold down the value of the yen, a move that would no doubt cause concern in the United States.

It is, however, very doable, as Switzerland has shown. When the euro zone debt crisis was at its worst, Switzerland became a safe haven for European investors worried that the euro might blow up. That drove up the value of the Swiss franc versus the euro and damaged Switzerland’s ability to compete. The Swiss government responded by announcing that the euro would not be allowed to fall below 1.2 Swiss francs. If necessary, the government would simply sell francs to meet any demand.

That has been necessary, and the Swiss have accumulated a huge portfolio of foreign currency. So, too, could the Japanese if they chose to announce that the dollar would henceforth be worth at least 100 yen, a level not seen since 2009.

Doing so would instantly restore at least some competitiveness to Japanese industry, which has experienced something that would have seemed impossible only a few years ago: Japan has a trade deficit.

Bringing inflation to Japan could make the country’s debt load — now higher than that of any other major country — appear more manageable. One unfortunate result of deflation coupled with perennial recession is that a country’s debt-to-G.D.P. ratio rises even if no more money is borrowed. Measured in yen, the Japanese economy was larger when Mr. Abe left office in 2007 — two years before his party lost power — than it is now.

A stronger recovery in the United States, not to mention avoiding a new Europe-wide downturn, would make it easier for Japan to begin to grow again. But even if that did happen, it would not solve all of Japan’s problems. The country has an aging, shrinking population. It needs more workers, but the Japanese attitude toward immigration makes Arizona look liberal by comparison.

Japan’s economy has been adrift for so long that much of the world takes for granted that it cannot, or at least will not, ever be reformed. Such cynicism has a basis, but it is possible that circumstances have changed. Japanese who seemed content with the way things were now clearly want something different, even if they are not sure what, or how to get it.

Three years ago, the Democratic Party of Japan won a landslide election, only to prove stumbling and incoherent when it tried to govern. Now the voters have turned back to the Liberal Democrats. Whether Mr. Abe will be more competent, and whether he will be able to effectively lead a party that still has competing factions, is far from clear.

Still, investors are taking heart. Japanese stocks leapt on the news of the election results, while the yen weakened. For now, at least, there is reason to hope that something important was changed by this election.

Floyd Norris comments on finance and the economy at nytimes.com/economix.

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RIM loses BlackBerry subscribers for first time

TORONTO (AP) — Research In Motion‘s stock plunged in after-hours trading Thursday after the BlackBerry maker said it plans to change the way it charges fees.

RIM also announced that it lost subscribers for the first time in the latest quarter, as the global number of BlackBerry users dipped to 79 million.

In a rare positive sign, the Canadian company added to its cash position during the quarter as it prepared to launch new smartphones on Jan. 30. The new devices are deemed critical to the company’s survival.

RIM’s stock initially jumped more than 8 percent in after-hours trading on that news, but then fell $ 1.48, or 10.4 percent, to $ 12.65 after RIM said on a conference call that it won’t generate as much revenue from telecommunications carriers once it releases the new BlackBerry 10 platform.

RIM is changing the way it charges service fees, putting an important source of revenue at risk. RIM CEO Thorsten Heins said only subscribers who want enhanced security will pay fees under the new system.

“Other subscribers who do not utilize such services are expected to generate less or no service revenue,” Heins said. “The mix in level of service fees revenue will change going forward and will be under pressure over the next year during this transition.”

RIM’s stock had been on a three-month rally that has seen the stock more than double from its lowest level since 2003.

But Mike Walkley, an analyst with Canaccord Genuity, said BlackBerry 10 will change RIM’s services revenue model dramatically. He said that instead of getting about $ 6 per device each month from carriers and users RIM could get as little as zero.

“That’s what turned the stock from being up 10 percent to being down 10 percent,” Walkley said. “That’s been part of our worry. How do they come back with a new platform and get carriers to continue to share the higher revenue —which sounds like they are not going to— and then subsidize the phone to make it affordable for consumers and enterprises.”

“People are seeing that the services revenue has a lot of risk to it now with the BlackBerry 10 migration.”

Three months ago, RIM had 80 million subscribers. Analysts said the loss of 1 million subscribers was expected. Once coveted symbols of an always-connected lifestyle, BlackBerry phones have lost their luster to Apple’s iPhone and phones that run on Google’s Android software.

RIM is banking its future on its much-delayed BlackBerry 10 platform, which is meant to offer the multimedia, Internet browsing and apps experience that customers now demand.

“We believe the company has stabilized and will turn the corner in the next year,” Heins said. He noted that the company’s cash holdings grew by $ 600 million in the quarter to $ 2.9 billion, even after the funding of all its restructuring costs. RIM previously announced 5,000 layoffs this year.

Heins said subscribers in North America showed the largest decline, but said there is growth overseas.

Colin Gillis, an analyst with BGC Financial, said before the conference call that the company bought itself more time.

“It doesn’t mean (BlackBerry) 10 will gain traction. A lot of people said 10 would be DOA, but I don’t think that’s going to be the case,” he said.

Jefferies analyst Peter Misek also earlier called the results better than expected, noting that RIM added a significant amount of cash. RIM will need the money to advertise the new BlackBerrys and operating system.

Misek also called it a positive development that RIM said there would not be another delay to BlackBerry 10.

“The success or failure of this company will be on BlackBerry 10,” Misek said.

RIM posted net income of $ 14 million, or 3 cents per share for its fiscal third quarter, which ended Dec. 1. That compares with a profit of $ 265 million, or 51 cents per share, in the same quarter a year ago.

The latest figure includes a favorable tax settlement. Excluding that adjustment, RIM lost 22 cents per share. Analysts polled by FactSet were expecting a wider loss of 27 cents.

RIM reported revenue of $ 2.7 billion, down 47 percent from a year ago.

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Michael Phelps voted AP male athlete of year

Now that he's away from the pool, Michael Phelps can reflect — really reflect — on what he accomplished.

Pretty amazing stuff.

"It's kind of nuts to think about everything I've gone through," Phelps said. "I've finally had time to myself, to sit back and say, '... that really happened?' It's kind of shocking at times."

Not that his career needed a capper, but Phelps added one more honor to his staggering list of accomplishments Thursday — The Associated Press male athlete of the year.

Phelps edged out LeBron James to win the award for the second time, not only a fitting payoff for another brilliant Olympics (four gold medals and two silvers in swimming at the London Games) but recognition for one of the greatest careers in any sport.

Phelps finished with 40 votes in balloting by U.S. editors and broadcasters, while James was next with 37. Track star Usain Bolt, who won three gold medals in London, was third with 23.

Carl Lewis is the only other Olympic-related star to be named AP male athlete of the year more than once, taking the award for his track and field exploits in 1983 and '84. The only men honored more than twice are golf's Tiger Woods and cyclist Lance Armstrong (four times each), and basketball's Michael Jordan (three times).

"Obviously, it's a big accomplishment," Phelps said. "There's so many amazing male athletes all over the world and all over our country. To be able to win this is something that just sort of tops off my career."

Phelps retired at age 27 as soon as he finished his final race in London, having won more gold medals (18) and overall medals (22) than any other Olympian.

No one else is even close.

"That's what I wanted to do," Phelps said. "Now that it's over, it's something I can look back on and say, 'That was a pretty amazing ride.'"

The current ride isn't so bad either.

Set for life financially, he has turned his fierce competitive drive to golf, working on his links game with renowned coach Hank Haney as part of a television series on the Golf Channel. In fact, after being informed of winning the AP award, Phelps called in from the famed El Dorado Golf & Beach Club in Los Cabos, Mexico, where he was heading out with Haney to play a few more holes before nightfall.

"I can't really complain," Phelps quipped over the phone.

Certainly, he has no complaints about his swimming career, which helped turn a sport that most Americans only paid attention to every four years into more of a mainstream pursuit.

More kids took up swimming. More advertisers jumped on board. More viewers tuned in to watch.

While swimming is unlikely to ever match the appeal of football or baseball, it has carved out a nice little niche for itself amid all the other athletic options in the United States — largely due to Phelps' amazing accomplishments and aw-shucks appeal.

Just the fact that he won over James shows just how much pull Phelps still has. James had an amazing year by any measure: The league MVP won his first NBA title with the Miami Heat, picking up finals MVP honors along the way, and then starred on the gold medal-winning U.S. basketball team in London.

Phelps already had won the AP award in 2008 after his eight gold medals in Beijing, which broke Mark Spitz's record. Phelps got it again with a performance that didn't quite match up to the Great Haul of China, but was amazing in its own right.

After the embarrassment of being photographed taking a hit from a marijuana pipe and questioning whether he still had the desire to go on, Phelps returned with a vengeance as the London Games approached. Never mind that he was already the winningest Olympian ever. Never mind that he could've eclipsed the record for overall medals just by swimming on the relays.

He wanted to be one of those rare athletes who went out on top.

"That's just who he is," said Bob Bowman, his longtime coach. "He just couldn't live with himself if knew he didn't go out there and give it good shot and really know he's competitive. He doesn't know anything else but to give that kind of effort and have those kind of expectations."

Phelps got off to a rocky start in London, finishing fourth in the 400-meter individual medley, blown out of the water by his friend and rival, Ryan Lochte. It was only the second time that Phelps had not at least finished in the top three of an Olympic race, the first coming way back in 2000 when he was fifth in his only event of the Sydney Games as a 15-year-old.

To everyone looking in, Lochte seemed poised to become the new Phelps — while the real Phelps appeared all washed up.

But he wasn't going out like that.

No way.

Phelps rebounded to become the biggest star at the pool, edging Lochte in the 200 IM, contributing to a pair of relay victories, and winning his final individual race, the 100 butterfly. There were two silvers, as well, leaving Phelps with a staggering resume that will be awfully difficult for anyone to eclipse.

His 18 golds are twice as many as anyone else in Olympic history. His 22 medals are four clear of Larisa Latynina, a Soviet-era gymnast, and seven more than the next athlete on the list. Heck, if Phelps was a nation, he'd be 58th in the medal standings, just one behind India (population: 1.2 billion).

"When I'm flying all over the place, I write a lot in my journal," Phelps said. "I kind of relive all the memories, all the moments I had throughout my career. That's pretty special. I've never done that before. It's amazing when you see it all on paper."

Four months into retirement, Phelps has no desire to get back in the pool. Oh, he'll swim every now and then for relaxation, using the water to unwind rather than putting in one of his famously grueling practices. Golf is his passion at the moment, but he's also found time to cheer on his hometown NFL team, the Baltimore Ravens, and start looking around for a racehorse that he and Bowman can buy together.

Phelps hasn't turned his back on swimming, either. He's got his name attached to a line of schools that he wants to take worldwide. He's also devoting more time to his foundation, which is dedicated to teaching kids to swim and funding programs that will grow the sport even more.

He's already done so much.

"His contribution to the way the world thinks about swimming is so powerful," Bowman said. "I don't think any other athlete has transformed his sport the way he's transformed swimming."

Phelps still receives regular texts from old friends and teammates, asking when he's going to give up on this retirement thing and come back the pool as a competitor.

He scoffs at the notion, sounding more sure of himself now than he did in London.

And if there's anything we've learned: Don't doubt Michael Phelps when he sets his mind on something.

"Sure, I could come back in another four years. But why?" he asked, not waiting for an answer. "I've done everything I wanted to do. There's no point in coming back."

___

Follow Paul Newberry on Twitter at www.twitter.com/pnewberry1963

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Four State Department Officials Resign After Benghazi Report

WASHINGTON — Four State Department officials were removed from their posts on Wednesday after an independent panel criticized the “grossly inadequate” security  at a diplomatic compound in Benghazi that was attacked on Sept. 11, leading to the deaths of Ambassador J. Christopher Stevens and three other Americans.

Eric Boswell, the assistant secretary of state for diplomatic security, resigned. Charlene Lamb, the deputy assistant secretary responsible for embassy security, and another official in the diplomatic security office whom officials would not identify were relieved of their duties. So was Raymond Maxwell, a deputy assistant secretary who had responsibility for the North Africa region. The four officials, a State Department spokeswoman said, "have been placed on administrative leave pending further action." 

The report by the independent panel has criticized officials in State’s bureau for Diplomatic Security displaying a "lack of proactive leadership." It also said that some in the Bureau of Near Eastern Affairs "showed a lack of ownership of Benghazi’s security issues." 

The report did not criticize more senior officials, including Patrick F. Kennedy, the under secretary for management, who has vigorously defended the State Department’s decision-making on Benghazi to the Congress and Secretary of State Hillary Rodham Clinton.

At a news conference at the State Department on Wednesday, Thomas R. Pickering, a former ambassador who led the independent review, said that most of the blame should fall on officials in the two bureaus.

“We fixed it at the assistant secretary level, which is, in our view, the appropriate place to look, where the decision-making in fact takes place, where, if you like, the rubber hits the road,” said Mr. Pickering, who did not identify the officials.

At the same time, the report that Mr. Pickering oversaw suggested that there was a culture of “husbanding resources” at senior levels of the State Department that contributed to the security deficiencies in Benghazi. Without identifying Mr. Kennedy or other senior officials, the report said that attitude “had the effect of conditioning a few State Department managers to favor restricting the use of resources as a general orientation.”

Two deputy secretaries of state, William J. Burns and Thomas R. Nides, are scheduled to testify to Congressional committees on Thursday. The question of whether senior officials at the State Department should be held accountable is likely to be raised by lawmakers at the hearing.

“The board severely critiques a handful of individuals, and they have been held accountable,” said Representative Ed Royce, Republican of California, who is the incoming chairman of the House Foreign Affairs Committee. “The degree that others bear responsibility warrants Congressional review, given the report’s rather sweeping indictment. And the Foreign Affairs Committee must hear from Secretary Clinton concerning her role, which this report didn’t address.”

Mrs. Clinton, in a letter to Congress, outlined a number of steps the department is taking to improve security, including hiring hundreds of additional Marine guards for high-risk embassies and consulates around the world.

In an apparent gesture of support for the American diplomatic corps, President Obama praised the State Department’s personnel, whom he said often worked "at great risk," at a diplomatic reception at the State Department tonight.

Another issue, which might be raised and which was largely skirted by the independent panel, concerns what role the American military should play in protecting diplomats abroad.

The Pentagon had no forces that could be readily sent to Benghazi when the crisis unfolded. The closest AC-130 gunship was in Afghanistan. There are no armed drones thought to be within range of Libya. There was no Marine expeditionary unit — a large seaborne force with its own helicopters — in the Mediterranean Sea. The Africa Command, whose area of operation includes North Africa, also did not have on hand its own force able to respond rapidly to emergencies — a Commanders’ In-Extremis Force, or C.I.F. Every other regional combatant command had one at the time.

The Defense Department has repeatedly declined to say whether the Africa Command requested that any of these forces be on hand during the anniversary of the Sept. 11, 2001, terrorist attacks. Nor has it said whether Defense Secretary Leon E. Panetta or Gen. Martin E. Dempsey, the chairman of the Joint Chiefs of Staff, gave any thought to moving forces in the region as a precaution.

The unclassified version of the Benghazi report concluded that “there simply was not enough time given the speed of the attacks for armed U.S. military assets to have made a difference.” But the report did not address whether it would have been prudent to station quick-reaction forces in the region or whether the United States would have been in a position to quickly respond militarily had Ambassador Stevens been kidnapped and the crisis dragged on, as was initially feared.

The United States military’s best-trained team to extract diplomats under fire — Delta Force commandos — was half a world away, in Fort Bragg, N.C. “What this report shows is that we need a fundamental rethink of the problem,” said one senior Pentagon official who has spent considerable time examining the issue of protecting American diplomats since the attack in September. “It’s not the military’s job to protect diplomats; it’s the host government’s. But in the absence of a real government, we never asked the question, ‘So how do we do this?’ ”

But as the military budget declines, some ranking officers are wary about taking on new commitments, even ones that involve protecting Americans.

“It is not reasonable nor feasible to tether U.S. forces at the ready to respond to protect every high-risk post in the world,” Mike Mullen, the retired admiral and former chairman of the Joint Chiefs of Staff, who served as vice chairman of the independent review, said Wednesday.

David E. Sanger contributed reporting.

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Apple is dominating the small and medium business market in Q4

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Cruz: Meeting Pinto family was "toughest by far"

EAST RUTHERFORD, N.J. (AP) — For much of his hour-long visit with the family of a 6-year-old boy killed in the Connecticut school shootings, Victor Cruz talked about football, life and young Jack, the child who idolized him.

Tears were shed. Feelings were shared. Cleats and gloves worn by Cruz to honor Jack Pinto at Sunday's game against Atlanta were given to his family.

The New York Giants wide receiver somberly recounted Wednesday his meeting with Pinto's parents and brother in Newtown, Conn.

He struggled in his retelling only when asked about the family's decision to bury the child in the receiver's No. 80 Giants jersey. The father of an infant girl, Cruz stopped for a moment, and his eyes became watery.

"You never go through some circumstances like this and circumstances where a kid faces or a family faces something of this magnitude at their school," Cruz said. "This definitely was the toughest by far."

Jack Pinto was buried on Monday and Cruz telephoned the family to ask whether he could visit them Tuesday.

The family disclosed after Friday's massacre that Cruz was Jack's favorite player. The boy was one of 20 first-graders and six adults killed in the shootings at the Sandy Hook Elementary School.

Cruz drove to Newtown with his girlfriend, Elaina Watley, and their daughter, Kennedy.

"I had no expectations. I was a little nervous," Cruz said. "I just didn't know how I was going to be received. You never know when they are going through something like that. You never know how it is going to go down."

Seeing the family outside the home along with some local children made Cruz feel better.

"They were still pretty emotional, crying and stuff like that," Cruz said. "I saw how affected they were by just my presence alone. I got out and gave them the cleats and the gloves and they appreciated it. The older brother (Ben) was still emotional, so I gave them to him."

Cruz had written "Jack Pinto, My Hero" and "R.I.P. Jack Pinto" on his cleats before the Giants' loss to the Falcons Sunday in Atlanta.

The 26-year-old player best known for his salsa dances after touchdowns, signed autographs for the children before heading inside.

"I didn't want to go in there and make a speech," Cruz said. "I just wanted to go and spend some time with them and be someone they could talk to, and be someone they can vent to, talk about how much of a fans they are of the team, or different times they watched the Super Bowl."

Cruz spent that part of the visit sitting in the chair where Jack's father, Dean, sat when he watched the Giants' Super Bowl win over the New England Patriots in February.

It was a day Jack got to see his favorite team win a championship.

"It was just an emotional time," Cruz said. "I spent a little bit of time with them. We got to smile a little bit, which was good for them. It was a time where I just wanted to be a positive voice, a positive light in the tunnel where it can really be negative, so it was a good time. They are a great family and they're really united at this time and it was good to see."

Cruz said it was strange thinking about a child being buried in his jersey. He did not know how to react. Should he thank the family?

"It leaves you kind of blank," Cruz said. "I am definitely honored by it. I am definitely humbled by it, and it's definitely an unfortunate but humbling experience for me."

The visit also gave Cruz time to reflect, especially looking at his daughter.

"Ever since it happened I've kind of been spending more time with her, just cherishing the little moments, the little time you get with her because you never know when that can be taken from you," he said.

Giants coach Tom Coughlin said he was incredibly proud of Cruz for visiting with the Pinto family.

"Hopefully some of their grief might at least temporarily be suspended in being able to embrace Victor Cruz," Coughlin said, adding what he did speaking volumes of what he has inside.

Baltimore Ravens running back Ray Rice said what Cruz did took heart.

"You've got to be able to put yourself in that family's situation to understand at least what they're going through," Rice said in a conference call with the New York media about Sunday's game against the Giants. "That's what it's about. That's something that you don't just say, 'I'm going to do it.' You do it from the heart, from within and what he did was amazing."

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Online: http://pro32.ap.org/poll and http://twitter.com/AP_NFL

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Amgen Workers Helped U.S. in Aranesp Marketing Inquiry

“I hope no one is taping this,” the Amgen manager remarked at a company sales meeting in 2005.

The manager then boasted of how she had given a $10,000 unrestricted grant to a pet project of a doctor who was an adviser to the local Medicare contractor. In turn, she said, the doctor would help persuade the contractor to provide reimbursement for an unapproved use of Amgen’s anemia drug, Aranesp.

Someone, it turned out, was taping it. Jill Osiecki, a longtime sales representative at Amgen, was wearing a recording device under her clothes, transmitting the proceedings to agents of the Department of Health and Human Services.

The result of Ms. Osiecki’s undercover work, and information provided by other whistle-blowers, led to Amgen’s agreement this week to pay $762 million to settle federal investigations regarding the marketing of some of its top-selling drugs.

Judge Sterling Johnson Jr. of Federal District Court in Brooklyn accepted the settlement on Wednesday, clearing the way for 10 whistle-blower lawsuits to be unsealed.

Amgen, the world’s largest biotechnology company, will pay $150 million in criminal penalties after pleading guilty to one misdemeanor count of marketing Aranesp for unapproved uses and in unapproved doses.

The rest of the money — $612 million — will go to settle civil false claims lawsuits filed by the federal government, states and whistle-blowers. These contain accusations that go well beyond the off-label marketing of Aranesp.

They include off-label marketing of other drugs like Enbrel for psoriasis and Neulasta, which increases the levels of white blood cells. Amgen is also accused of offering kickbacks to doctors and clinics to induce them to use its drugs. These reportedly came as cash, rebates, free samples, educational and research grants, dinners and travel, and other inducements. The government also accused the company of knowingly misreporting the prices of some of its drugs.

Except for those in the criminal count, Amgen denied the other accusations, though it did issue a statement on Wednesday acknowledging the settlement.

“The government raised important concerns in the criminal prosecution,” Cynthia M. Patton, chief compliance officer at Amgen, said in the statement. “Amgen acknowledges that mistakes were made, and we did not live up to our standards.”

Ms. Osiecki, 52, was one of the main whistle-blowers and will be entitled to a share of the settlement. The amount each whistle-blower will receive has not been determined or is being kept confidential, their lawyers said.

Ms. Osiecki worked as a sales representative for Merck for nine years before joining Amgen in 1990, soon after the biotechnology company won regulatory approval for its first product. The company, based outside Los Angeles, had “good science, good products, strong ethics,” Ms. Osiecki said in an interview.

But, she said, the corporate culture changed starting around 2000. That was when new management came in and Aranesp was approved, setting up a fierce marketing battle with Johnson & Johnson and its rival anemia drug, Procrit.

“It was more important to make your numbers than to follow the rules,” said Ms. Osiecki, who was based in Milwaukee and sold Aranesp.

In August 2004, with her concerns mounting, Ms. Osiecki called the Office of Inspector General of the Department of Health and Human Services and left a message. Within days, she was called back, and she went to see an agent, who persuaded her to secretly record meetings. She did that 13 times over about 15 months, mainly sales meetings.

Aranesp is used mainly in a hospital, clinic or physician’s office. It is bought by the medical practice, which can make a profit if the patient and insurers pay more for the use of the drug than the practice paid.

Ms. Osiecki said Amgen “marketed the spread,” trying to make it more profitable for doctors to use Aranesp rather than Procrit.

Such financial inducements could also spur greater overall use of a drug and can violate anti-kickback laws, said Ms. Osiecki’s lawyer, Brian P. Kenney of Kenney & McCafferty in Blue Bell, Pa.

Ms. Osiecki said the first sales meeting at which she wore the recording device, wrapped around her midriff under baggy clothes, was in October 2004 in a Milwaukee hotel. She could look down from the meeting room and see the car parked across the street containing the agent with the receiving device. She said she was not particularly nervous.

The speaker was a pharmacist from an oncology practice going through the numbers on how his practice could make a million dollars more a year using Aranesp rather than Procrit.

Ms. Osiecki said Amgen was careful to cover up such marketing. Spreadsheets showing doctors how much more money they could make using Aranesp were “homemade bread,” meaning they were created by each sales representative, not by the company. And representatives were told not to leave the presentations behind after showing them to doctors.

Her 107-page complaint, filed in late 2004, contains many other accusations.

Other whistle-blowers made other accusations. Kassie Westmoreland, a former sales representative, said Amgen overfilled vials of Aranesp, essentially providing free drugs to doctors. They could then bill Medicare or private insurers for the use of that drug, making an extra profit.

“Amgen was offering a kickback in the form of extra product subsidized by the taxpayers,” said Robert M. Thomas Jr., one of Ms. Westmoreland’s lawyers.

Elena Ferrante and Marc Engelman, both former sales representatives, contended that Amgen promoted Enbrel’s off-label use for mild psoriasis when the drug was approved only for moderate or severe cases of the disease.

Lydia Cotz, one of their lawyers, said the two refused to go along with the off-label marketing. They are now pursuing wrongful termination claims against Amgen in arbitration proceedings that Amgen requires be kept confidential, she said.

“It’s been a very long heroic journey for my clients,” she said.

Ms. Osiecki is now also a former Amgen sales representative. She said that she was fired in December 2005 after she let slip that she had retained a company voice mail message that she thought provided evidence of illegal activity. Leaving the pharmaceutical industry, she moved to Amelia Island, Fla. She now works for a small business.

Mosi Secret and Barry Meier contributed reporting.

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Adding to Rules for Online Privacy

In a move intended to give parents greater control over data collected about their children online, federal regulators on Wednesday broadened longstanding privacy safeguards covering children’s mobile apps and Web sites. Members of the Federal Trade Commission said they updated the rules to keep pace with the growing use of mobile phones and tablets by children.

The regulations also reflect innovations like voice recognition technology, global positioning systems and behavior-based online advertising, or ads tailored to an individual Internet user.

Regulators had not significantly changed the original rule, based on the Children’s Online Privacy Protection Act of 1998, or Coppa. That rule required operators of Web sites directed at children under 13 to notify parents and obtain their permission before collecting or sharing personal information — like first and last names, phone numbers, home addresses or e-mail addresses — from children.

The intent of that was to give parents control over entities seeking to collect information about their children so that parents could, among other things, prevent unwanted contact by strangers.

The new rule, unveiled at a news conference in Washington, significantly expands the types of companies required to obtain parental permission before knowingly collecting personal details from children, as well as the types of information that will require parental consent to collect.

Jon D. Leibowitz, the chairman of the trade commission, described the rule revision as a major advance for children’s privacy. “Congress enacted Coppa in the desktop era and we live in an era of smartphones and mobile marketing,” Mr. Leibowitz said. “This is a landmark update of a seminal piece of legislation.”

The agency’s expanded privacy protections for children also represent the first step in a larger effort by a few regulators and legislators to give adult consumers some rights to control data collected about them.

“The Coppa rule revisions which we are announcing today are a critical piece in our overall approach to how we deal with consumer privacy in this technological age,” said Julie Brill, a member of the commission.

Industry analysts said the new rule represented a partial victory for Web site operators, app developers and advertising networks because regulators watered down some of their original proposals to which companies like Apple, Facebook, Google and Twitter had objected. Apple and Google, for example, opposed proposals that suggested they would be responsible for the data collected by children’s apps sold in their app stores. Regulators have now clarified that general-interest app stores would not be held liable for that.

Yet, few companies lent any support to the commission at its news conference; Viacom and Disney sent representatives, but other companies were absent.

“What we’ve got here is an expansion of Coppa that some in the industry would say has gone too far,” said Alan Friel, a lawyer who leads the media and technology practice at the firm of Edwards Wildman Palmer. “But the F.T.C. has provided exceptions that continue to allow internal use of a child’s data, including one-time use of contact information for facilitating promotions and send-a-friend e-mails.”

In an era of widespread photo sharing, video chatting and location-based apps, the revised children’s privacy rule makes clear that companies must obtain parental consent before collecting certain details that could be used to identify, contact or locate a child. These include photos, video and audio as well as the location of a child’s mobile device.

While the new rule strengthens such safeguards, it could also disrupt online advertising. Web sites and online advertising networks often use persistent identification systems — like a cookie in a person’s browser, the unique serial number on a mobile phone, or the I.P. address of a computer — to collect information about a user’s online activities and tailor ads for that person.

The new rule expands the definition of personal information to include persistent IDs if they are used to show a child behavior-based ads. It also requires third parties like ad networks and social networks that know they are operating on children’s sites to notify and obtain consent from parents before collecting such personal information. And it makes children’s sites responsible for notifying parents about data collection by third parties integrated into their services.

Collecting data to show children contextual ads based on the content of a site or app, however, will not require parental consent. “The only limit we place is on behavioral advertising,” Mr. Leibowitz said. “Until and unless you get parental consent, you may not track children to create massive profiles” for behavior-based ads.

Stuart P. Ingis, a lawyer representing several marketing associations, said that reputable online marketers did not knowingly profile children to show them behavior-based ads. He added that industry guidelines prohibited the practice.

He agreed with regulators that privacy protections for children online needed to keep pace with new technologies. But he said he was concerned that the restrictions on cookie-based identifiers might cause some children’s sites to reduce their use of ad networks to avoid having to notify parents about data collection by those services.

“There might be overreaction that would limit just general third-party collection of data, which is very useful to businesses and consumers,” said Mr. Ingis, who represents the Direct Marketing Association and the Association of National Advertisers.

The revised rule also clarifies requirements for sites that are not primarily directed at young children but whose audience may include them, like a Disney family site, for example. Those sites can now screen visitors by age, but they will be required to obtain permission from a parent to collect personal data about children under 13.

Children’s advocates generally welcomed the strengthened protections.

“Clearly, this is a major step forward, but the devil is in the details,” said Jeffrey Chester, the executive director of the Center for Digital Democracy, an advocacy group in Washington.

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Russia Sends Warships Toward Syria for Possible Evacuation

MOSCOW — Russia sent warships to the eastern Mediterranean Sea on Tuesday, the Defense Ministry announced, in what appeared to be preparation for a possible evacuation of Russian citizens from Syria.

Russian officials began formulating plans during the summer for an evacuation, but have delayed announcements, analysts say, to avoid signaling a loss of confidence in President Bashar al-Assad, a longtime strategic ally. Moscow staunchly opposes international intervention in Syria and has blocked United Nations Security Council resolutions meant to force Mr. Assad from power. Officials have repeatedly said that Russia’s position has not changed.

However, Moscow has signaled in recent days that it sees Mr. Assad’s forces losing ground, and that it is beginning to prepare for a chaotic transition period. One immediate concern is the large number of Russian citizens scattered across Syria, as a result of decades of intermarriage and longstanding economic ties.

Late on Monday, Russian diplomats said that two Russian citizens had been kidnapped by an armed group. The two Russians, evidently workers in a privately owned steel factory, were seized as they traveled on a road between Homs and Tartus and were held for ransom. An Italian citizen, Mario Belluomo, was abducted with them, the Italian Foreign Ministry said.

Then on Tuesday, the Russian Defense Ministry announced that a flotilla of five ships — a destroyer, a tugboat, a tanker and two large landing vessels — was being sent from Baltiysk, a port in the Baltic Sea, to relieve ships that have been near Syria for months. At typical cruising speeds for such vessels, the ships would arrive on station around the beginning of January.

A naval official, speaking on the condition of anonymity as is customary, told the Interfax news service that the ships were “on their way to the coast of Syria for possible participation in the evacuation of Russian citizens” to a Russian port on the Black Sea. The official said that the mission had been planned swiftly but under total secrecy, and that the timeline for the ships’ return to port “depends on the development of the situation in Syria.”

Aleksandr I. Shumilin, a regional analyst and a foreign correspondent, said Russian leaders had avoided openly taking steps toward evacuation until now, to avoid signaling that Russia was scaling back its support for Mr. Assad, but that they also risked public anger if Russians became targets of violence in Syria.

“It appears that some break has taken place, but whether that means a change of policy, or a modification of policy, that’s hard to say,” said Mr. Shumilin, who is head of the Middle East conflict analysis center at the Russian Academy of Science’s Institute for Canada and the United States. “The decision-makers are now concentrating on humanitarian questions, the protection of Russian citizens.”

The Syrian rebels have been moving aggressively around the capital, Damascus, in recent weeks, and Mr. Assad’s forces have responded by firing with Scud missiles. On Tuesday, Syrian fighter jets bombed the Palestinian refugee camp of Yarmouk for the second time this week, seeking to drive back rebel forces that had moved in, The Associated Press reported.

Iran, Syria’s last ally in its region, appeared to remain firmly committed to Mr. Assad. On Tuesday, Deputy Foreign Minister Hossein Amir Abdollahianof Iran told reporters in Moscow, “The Syrian Army and the state machine are working smoothly.”

A planned visit by the president of Iran, Mahmoud Ahmadinejad, to Ankara, the capital of Turkey, was suddenly canceled on Monday amid tensions between Iran and Turkey over NATO’s decision to deploy Patriot antimissile batteries on the Turkish border with Syria.

Iranian leaders, politicians and commanders of the Islamic Revolutionary Guards Corps have denounced NATO’s decision on Dec. 4 to send six batteries of American, German and Dutch Patriot systems to intercept any Scud missiles that the embattled Syrian government may launch toward Turkey.

Iran fears that NATO will use the batteries, which are staffed by about 1,000 soldiers and can also be used against aircraft, to set up a no-fly zone and create a rebel safe haven in northern Syria.

Iran’s top general, Hassan Firouzabadi, said at a meeting of senior commanders on Saturday that the deployment was part of a Western plan to start a “world war,” and that Iran’s own ambitious missile program was the real target.

“They signify concerns over Iran’s missiles and the presence of Russia for defending Syria,” he said. “The sensible people in America, Turkey and Europe must prevent this situation from getting out of control.”

The mobile Patriot systems could technically be used to intercept Iranian as well as Syrian missiles. They are effective against missiles at a range of about 12 miles, and against aircraft up to 100 miles.

Iran has threatened to fire missiles at Israel if its nuclear installations come under attack.

On Tuesday, Iran’s defense minister, Brig. Gen. Ahmad Vahidi, said Israel was the winner in the Syrian conflict, because it was witnessing the destruction of an enemy — the Assad government — while the Syrian people were being “manipulated” by “terrorists.”

Turkey’s foreign minister, Ahmet Davutoglu, urged Iran to use its political clout with Damascus to end the violence in Syria, instead of making statements about the Patriot systems.

“Turkey and NATO have stressed over and over again that this system is solely for defensive purposes,” Mr. Davutoglu told reporters. “Turkey has the right to do what it wants in order to protect its territory. It is time for Iran to give a clear message to the Syrian regime.”

Ellen Barry reported from Moscow, and Thomas Erdbrink from Tehran.

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