Doctors Who Work for Hospitals Face a New Bottom Line

For decades, doctors in picturesque Boise, Idaho, were part of a tight-knit community, freely referring patients to the specialists or hospitals of their choice and exchanging information about the latest medical treatments.

But that began to change a few years ago, when the city’s largest hospital, St. Luke’s Health System, began rapidly buying physician practices all over town, from general practitioners to cardiologists to orthopedic surgeons.

Today, Boise is a medical battleground.

A little over half of the 1,400 doctors in southwestern Idaho are employed by St. Luke’s or its smaller competitor, St. Alphonsus Regional Medical Center.

Many of the independent doctors complain that both hospitals, but especially St. Luke’s, have too much power over every aspect of the medical pipeline, dictating which tests and procedures to perform, how much to charge and which patients to admit.

In interviews, they said their referrals from doctors now employed by St. Luke’s had dropped sharply, while patients, in many cases, were paying more there for the same level of treatment.

Boise’s experience reflects a growing national trend toward consolidation. Across the country, doctors who sold their practices and signed on as employees have similar criticisms. In lawsuits and interviews, they describe growing pressure to meet the financial goals of their new employers — often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay.

In Boise, just a few weeks ago, even the hospitals were at war. St. Alphonsus went to court seeking an injunction to stop St. Luke’s from buying another physician practice group, arguing that the hospital’s dominance in the market was enabling it to drive up prices and to demand exclusive or preferential agreements with insurers. The price of a colonoscopy has quadrupled in some instances, and in other cases St. Luke’s charges nearly three times as much for laboratory work as nearby facilities, according to the St. Alphonsus complaint.

Federal and state officials have also joined the fray. In one of a handful of similar cases, the Federal Trade Commission and the Idaho attorney general are investigating whether St. Luke’s has become too powerful in Boise, using its newfound leverage to stifle competition.

Dr. David C. Pate, chief executive of St. Luke’s, denied the assertions by St. Alphonsus that the hospital’s acquisitions had limited patient choice or always resulted in higher prices. In some cases, Dr. Pate said, services that had been underpriced were raised to reflect market value. St. Luke’s, he argued, is simply embracing the new model of health care, which he predicted would lead over the long term to lower overall costs as fewer unnecessary tests and procedures were performed.

Regulators expressed some skepticism about the results, for patients, of rapid consolidation, although the trend is still too new to know for sure. “We’re seeing a lot more consolidation than we did 10 years ago,” said Jeffrey Perry, an assistant director in the F.T.C.’s Bureau of Competition. “Historically, what we’ve seen with the consolidation in the health care industry is that prices go up, but quality does not improve.”

A Drive to Consolidate

An array of new economic realities, from reduced Medicare reimbursements to higher technology costs, is driving consolidation in health care and transforming the practice of medicine in Boise and other communities large and small. In one manifestation of the trend, hospitals, private equity firms and even health insurance companies are acquiring physician practices at a rapid rate.

Today, about 39 percent of doctors nationwide are independent, down from 57 percent in 2000, according to estimates by Accenture, a consulting firm.

Many policy experts praise the shift away from independent practices as a way of making health care less fragmented and expensive. Systems that employ doctors, modeled after well-known organizations like Kaiser Permanente, are better able to coordinate patient care and to find ways to deliver improved services at lower costs, these advocates say. Indeed, consolidation is encouraged by some aspects of the Obama administration’s health care law.

“If you’re going to be paid for value, for performance, you’ve got to perform together,” said Dr. Ricardo Martinez, chief medical officer for North Highland, an Atlanta-based consultant that works with hospitals.

The recent trend is reminiscent of the consolidation that swept the industry in the 1990s in response to the creation of health maintenance organizations, or H.M.O.’s — but there is one major difference. Then, hospitals had difficulty managing the practices, contending that doctors did not work as hard when they were employees as they had as private operators. Now, hospitals are writing contracts more in their own favor.

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Most Americans Face Lower Tax Burden Than in the 80s

What Is Fair?:
Taxes are still a hot topic after the presidential election. But as a country that spends more than it collects in taxes, are we asking the right taxpayers to pay the right amounts?

BELLEVILLE, Ill. — Alan Hicks divides long days between the insurance business he started in the late 1970s and the barbecue restaurant he opened with his sons three years ago. He earned more than $250,000 last year and said taxes took more than 40 percent. What’s worse, in his view, is that others — the wealthy, hiding in loopholes; the poor, living on government benefits — are not paying their fair share.

Kirsten Luce for The New York Times

"I don't have the answer of where to pull back. I want the state parks to stay open. I want, I want, I want. I want Big Bird, I think it's beautiful. What don't I want? I don't know," said Anita Thole, a safety supervisor for a utility contractor.

“It feels like the harder we work, the more they take from us,” said Mr. Hicks, 55, as he waited for a meat truck one recent afternoon. “And it seems like there’s an awful lot of people in the United States who don’t pay any taxes.”

These are common sentiments in the eastern suburbs of St. Louis, a region of fading factory towns fringed by new subdivisions. Here, as across the country, people like Mr. Hicks are pained by the conviction that they are paying ever more to finance the expansion of government.

But in fact, most Americans in 2010 paid far less in total taxes — federal, state and local — than they would have paid 30 years ago. According to an analysis by The New York Times, the combination of all income taxes, sales taxes and property taxes took a smaller share of their income than it took from households with the same inflation-adjusted income in 1980.

Households earning more than $200,000 benefited from the largest percentage declines in total taxation as a share of income. Middle-income households benefited, too. More than 85 percent of households with earnings above $25,000 paid less in total taxes than comparable households in 1980.

Lower-income households, however, saved little or nothing. Many pay no federal income taxes, but they do pay a range of other levies, like federal payroll taxes, state sales taxes and local property taxes. Only about half of taxpaying households with incomes below $25,000 paid less in 2010.

The uneven decline is a result of two trends. Congress cut federal taxation at every income level over the last 30 years. State and local taxes, meanwhile, increased for most Americans. Those taxes generally take a larger share of income from those who make less, so the increases offset more and more of the federal savings at lower levels of income.

In a half-dozen states, including Connecticut, Florida and New Jersey, the increases were large enough to offset the federal savings for most households, not just the poorer ones.

Now an era of tax cuts may be reaching its end. The federal government depends increasingly on borrowed money to pay its bills, and many state and local governments are similarly confronting the reality that they are spending more money than they collect. In Washington, debates about tax cuts have yielded to debates about who should pay more.

President Obama campaigned for re-election on a promise to take a larger share of taxable income above roughly $250,000 a year. The White House is now negotiating with Congressional Republicans, who instead want to raise some money by reducing tax deductions. Federal spending cuts also are at issue.

If a deal is not struck by year’s end, a wide range of federal tax cuts passed since 2000 will expire and taxes will rise for roughly 90 percent of Americans, according to the independent Tax Policy Center. For lower-income households, taxation would spike well above 1980 levels. Upper-income households would lose some but not all of the benefits of tax cuts over the last three decades.

Public debate over taxes has typically focused on the federal income tax, but that now accounts for less than a third of the total tax revenues collected by federal, state and local governments. To analyze the total burden, The Times created a model, in consultation with experts, which estimated total tax bills for each taxpayer in each year from 1980, when the election of President Ronald Reagan opened an era of tax cutting, up to 2010, the most recent year for which relevant data is available.

The analysis shows that the overall burden of taxation declined as a share of income in the 1980s, rose to a new peak in the 1990s and fell again in the 2000s. Tax rates at most income levels were lower in 2010 than at any point during the 1980s.

Governments still collected the same share of total income in 2010 as in 1980 — 31 cents from every dollar — because people with higher incomes pay taxes at higher rates, and household incomes rose over the last three decades, particularly at the top.

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Recipes for Health: Asian Chopped Salad With Seasoned Tofu ‘Fingers’ — Recipes for Health

Andrew Scrivani for The New York Times

I like to serve the baked seasoned tofu “fingers” warm on top of the salad. They are delicious cold, too; it is worth making up a separate batch for the refrigerator. If you have an assortment of vegetables leftover from Thanksgiving dinner, throw them in!

For the Tofu:

1/4 cup soy sauce

2 tablespoons mirin (sweet Japanese rice wine)

1 tablespoon rice vinegar

1 tablespoon minced or grated fresh ginger

1/2 teaspoon sugar

1 tablespoon Asian sesame oil

1 pound firm tofu

For the salad:

1 romaine heart, chopped

5 cups mixed chopped or diced vegetables such as:

Green or red cabbage

Celery (from the inner heart)

Red pepper

Radishes, sliced or chopped

1/4 cup dry roasted peanuts, coarsely chopped

1/4 cup chopped cilantro (more to taste)

1 serrano pepper, seeded and minced (optional)

For the dressing:

2 tablespoons fresh lime juice

1/4 cup tofu marinade, above

2 tablespoons canola or peanut oil

1/3 cup low-fat buttermilk or plain nonfat yogurt

1. Marinate the tofu: combine the soy sauce, mirin, rice vinegar, ginger and sugar in a 2-quart bowl. Whisk in the sesame oil and combine well. Drain the tofu and pat dry with paper towels. Slice into 1/3-inch thick slabs and cut the slabs in half lengthwise to get “fingers” approximately 1/3 inch thick by 3/4 inch wide. Blot each finger with paper towels. Add to the bowl with the marinade and gently toss to coat. Cover and refrigerate for 15 minutes to an hour, or for up to a day.

2. Meanwhile, heat the oven to 375 degrees and line a baking sheet with parchment. Lift the tofu out of the marinade and arrange the pieces on the parchment-covered baking sheet. Bake for 7 to 10 minutes, until the edges are just beginning to color and the marinade sets on the surface of the tofu. Remove from the heat.

3. In a large bowl, combine all of the salad ingredients. Whisk together the dressing ingredients and toss with the salad. If desired, transfer to a platter. Garnish with the tofu strips and serve.

Yield: Serves 4

Advance preparation: The chopped vegetables can be prepared up to a day ahead and refrigerated in a well covered container. The tofu marinade will keep for two days in the refrigerator. The baked seasoned tofu will keep for several days in the refrigerator.

Nutritional information per serving: 317 calories; 20 grams fat; 2 grams saturated fat; 8 grams polyunsaturated fat; 9 grams monounsaturated fat; 1 milligram cholesterol; 19 grams carbohydrates; 5 grams dietary fiber; 470 milligrams sodium (does not include salt to taste); 16 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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Recipes for Health: Asian Chopped Salad With Seasoned Tofu ‘Fingers’ — Recipes for Health

Andrew Scrivani for The New York Times

I like to serve the baked seasoned tofu “fingers” warm on top of the salad. They are delicious cold, too; it is worth making up a separate batch for the refrigerator. If you have an assortment of vegetables leftover from Thanksgiving dinner, throw them in!

For the Tofu:

1/4 cup soy sauce

2 tablespoons mirin (sweet Japanese rice wine)

1 tablespoon rice vinegar

1 tablespoon minced or grated fresh ginger

1/2 teaspoon sugar

1 tablespoon Asian sesame oil

1 pound firm tofu

For the salad:

1 romaine heart, chopped

5 cups mixed chopped or diced vegetables such as:

Green or red cabbage

Celery (from the inner heart)

Red pepper

Radishes, sliced or chopped

1/4 cup dry roasted peanuts, coarsely chopped

1/4 cup chopped cilantro (more to taste)

1 serrano pepper, seeded and minced (optional)

For the dressing:

2 tablespoons fresh lime juice

1/4 cup tofu marinade, above

2 tablespoons canola or peanut oil

1/3 cup low-fat buttermilk or plain nonfat yogurt

1. Marinate the tofu: combine the soy sauce, mirin, rice vinegar, ginger and sugar in a 2-quart bowl. Whisk in the sesame oil and combine well. Drain the tofu and pat dry with paper towels. Slice into 1/3-inch thick slabs and cut the slabs in half lengthwise to get “fingers” approximately 1/3 inch thick by 3/4 inch wide. Blot each finger with paper towels. Add to the bowl with the marinade and gently toss to coat. Cover and refrigerate for 15 minutes to an hour, or for up to a day.

2. Meanwhile, heat the oven to 375 degrees and line a baking sheet with parchment. Lift the tofu out of the marinade and arrange the pieces on the parchment-covered baking sheet. Bake for 7 to 10 minutes, until the edges are just beginning to color and the marinade sets on the surface of the tofu. Remove from the heat.

3. In a large bowl, combine all of the salad ingredients. Whisk together the dressing ingredients and toss with the salad. If desired, transfer to a platter. Garnish with the tofu strips and serve.

Yield: Serves 4

Advance preparation: The chopped vegetables can be prepared up to a day ahead and refrigerated in a well covered container. The tofu marinade will keep for two days in the refrigerator. The baked seasoned tofu will keep for several days in the refrigerator.

Nutritional information per serving: 317 calories; 20 grams fat; 2 grams saturated fat; 8 grams polyunsaturated fat; 9 grams monounsaturated fat; 1 milligram cholesterol; 19 grams carbohydrates; 5 grams dietary fiber; 470 milligrams sodium (does not include salt to taste); 16 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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Medicare Is Faulted in Electronic Medical Records Conversion

The conversion to electronic medical records — a critical piece of the Obama administration’s plan for health care reform — is “vulnerable” to fraud and abuse because of the failure of Medicare officials to develop appropriate safeguards, according to a sharply critical report to be issued Thursday by federal investigators.

Mike Spencer/Wilmington Star-News, via Associated Press

Celeste Stephens, a nurse, leads a session on electronic records at New Hanover Regional Medical Center in Wilmington, N.C.

Centers for Medicare and Medicaid Services

Marilyn Tavenner, acting administrator for Medicare.

The use of electronic medical records has been central to the aim of overhauling health care in America. Advocates contend that electronic records systems will improve patient care and lower costs through better coordination of medical services, and the Obama administration is spending billions of dollars to encourage doctors and hospitals to switch to electronic records to track patient care.

But the report says Medicare, which is charged with managing the incentive program that encourages the adoption of electronic records, has failed to put in place adequate safeguards to ensure that information being provided by hospitals and doctors about their electronic records systems is accurate. To qualify for the incentive payments, doctors and hospitals must demonstrate that the systems lead to better patient care, meeting a so-called meaningful use standard by, for example, checking for harmful drug interactions.

Medicare “faces obstacles” in overseeing the electronic records incentive program “that leave the program vulnerable to paying incentives to professionals and hospitals that do not fully meet the meaningful use requirements,” the investigators concluded. The report was prepared by the Office of Inspector General for the Department of Health and Human Services, which oversees Medicare.

The investigators contrasted the looser management of the incentive program with the agency’s pledge to more closely monitor Medicare payments of medical claims. Medicare officials have indicated that the agency intends to move away from a “pay and chase” model, in which it tried to get back any money it has paid in error, to one in which it focuses on trying to avoid making unjustified payments in the first place.

Late Wednesday, a Medicare spokesman said in a statement: “Protecting taxpayer dollars is our top priority and we have implemented aggressive procedures to hold providers accountable. Making a false claim is a serious offense with serious consequences and we believe the overwhelming majority of doctors and hospitals take seriously their responsibility to honestly report their performance.”

The government’s investment in electronic records was authorized under the broader stimulus package passed in 2009. Medicare expects to spend nearly $7 billion over five years as a way of inducing doctors and hospitals to adopt and use electronic records. So far, the report said, the agency has paid 74, 317 health professionals and 1,333 hospitals. By attesting that they meet the criteria established under the program, a doctor can receive as much as $44,000 for adopting electronic records, while a hospital could be paid as much as $2 million in the first year of its adoption. The inspector general’s report follows earlier concerns among regulators and others over whether doctors and hospitals are using electronic records inappropriately to charge more for services, as reported by The New York Times last September, and is likely to fuel the debate over the government’s efforts to promote electronic records. Critics say the push for electronic records may be resulting in higher Medicare spending with little in the way of improvement in patients’ health. Thursday’s report did not address patient care.

Even those within the industry say the speed with which systems are being developed and adopted by hospitals and doctors has led to a lack of clarity over how the records should be used and concerns about their overall accuracy.

“We’ve gone from the horse and buggy to the Model T, and we don’t know the rules of the road. Now we’ve had a big car pileup,” said Lynne Thomas Gordon, the chief executive of the American Health Information Management Association, a trade group in Chicago. The association, which contends more study is needed to determine whether hospitals and doctors actually are abusing electronic records to increase their payments, says it supports more clarity.

Although there is little disagreement over the potential benefits of electronic records in reducing duplicative tests and avoiding medical errors, critics increasingly argue that the federal government has not devoted enough time or resources to making certain the money it is investing is being well spent.

House Republicans echoed these concerns in early October in a letter to Kathleen Sebelius, secretary of health and human services. Citing the Times article, they called for suspending the incentive program until concerns about standardization had been resolved. “The top House policy makers on health care are concerned that H.H.S. is squandering taxpayer dollars by asking little of providers in return for incentive payments,” said a statement issued at the same time by the Republicans, who are likely to seize on the latest inspector general report as further evidence of lax oversight. Republicans have said they will continue to monitor the program.

In her letter in response, which has not been made public, Ms. Sebelius dismissed the idea of suspending the incentive program, arguing that it “would be profoundly unfair to the hospitals and eligible professionals that have invested billions of dollars and devoted countless hours of work to purchase and install systems and educate staff.” She said Medicare was trying to determine whether electronic records had been used in any fraudulent billing but she insisted that the current efforts to certify the systems and address the concerns raised by the Republicans and others were adequate.

This article has been revised to reflect the following correction:

Correction: November 30, 2012

An article on Thursday about a federal report critical of Medicare’s performance in assuring accuracy as doctors and hospitals switch to electronic medical records misstated, in some copies, the timing of a statement from a Medicare spokesman in response to the report. The statement was released late Wednesday, not late Thursday.

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General Assembly Grants Palestine Upgraded Status in U.N.

Damon Winter/The New York Times

The Palestinian Authority president, Mahmoud Abbas, center, was congratulated by Turkey’s foreign minister, Ahmet Davutoglu. More Photos »

UNITED NATIONS — More than 130 countries voted on Thursday to upgrade Palestine to a nonmember observer state of the United Nations, a triumph for Palestinian diplomacy and a sharp rebuke to the United States and Israel.

But the vote, at least for now, did little to bring either the Palestinians or the Israelis closer to the goal they claim to seek: two states living side by side, or increased Palestinian unity. Israel and the militant group Hamas both responded critically to the day’s events, though for different reasons.

The new status will give the Palestinians more tools to challenge Israel in international legal forums for its occupation activities in the West Bank, including settlement-building, and it helped bolster the Palestinian Authority, weakened after eight days of battle between its rival Hamas and Israel.

But even as a small but determined crowd of 2,000 celebrated in central Ramallah in the West Bank, waving flags and dancing, there was an underlying sense of concerned resignation.

“I hope this is good,” said Munir Shafie, 36, an electrical engineer who was there. “But how are we going to benefit?”

Still, the General Assembly vote — 138 countries in favor, 9 opposed and 41 abstaining — showed impressive backing for the Palestinians at a difficult time. It was taken on the 65th anniversary of the vote to divide the former British mandate of Palestine into two states, one Jewish and one Arab, a vote Israel considers the international seal of approval for its birth.

The past two years of Arab uprisings have marginalized the Palestinian cause to some extent as nations that focused their political aspirations on the Palestinian struggle have turned inward. The vote on Thursday, coming so soon after the Gaza fighting, put the Palestinians again — if briefly, perhaps — at the center of international discussion.

“The question is, where do we go from here and what does it mean?” Salam Fayyad, the Palestinian prime minister, who was in New York for the vote, said in an interview. “The sooner the tough rhetoric of this can subside and the more this is viewed as a logical consequence of many years of failure to move the process forward, the better.” He said nothing would change without deep American involvement.

President Mahmoud Abbas of the Palestinian Authority, speaking to the assembly’s member nations, said, “The General Assembly is called upon today to issue a birth certificate of the reality of the state of Palestine,” and he condemned what he called Israeli racism and colonialism. His remarks seemed aimed in part at Israel and in part at Hamas. But both quickly attacked him for the parts they found offensive.

“The world watched a defamatory and venomous speech that was full of mendacious propaganda against the Israel Defense Forces and the citizens of Israel,” Prime Minister Benjamin Netanyahu of Israel responded. “Someone who wants peace does not talk in such a manner.”

While Hamas had officially backed the United Nations bid of Mr. Abbas, it quickly criticized his speech because the group does not recognize Israel.

“There are controversial issues in the points that Abbas raised, and Hamas has the right to preserve its position over them,” said Salah al-Bardaweel, a spokesman for Hamas in Gaza, on Thursday.

“We do not recognize Israel, nor the partition of Palestine, and Israel has no right in Palestine,” he added. “Getting our membership in the U.N. bodies is our natural right, but without giving up any inch of Palestine’s soil.”

Israel’s ambassador to the United Nations, Ron Prosor, spoke after Mr. Abbas and said he was concerned that the Palestinian Authority failed to recognize Israel for what it is.

“Three months ago, Israel’s prime minister stood in this very hall and extended his hand in peace to President Abbas,” Mr. Prosor said. “He reiterated that his goal was to create a solution of two states for two peoples, where a demilitarized Palestinian state will recognize Israel as a Jewish state.

“That’s right. Two states for two peoples. In fact, President Abbas, I did not hear you use the phrase ‘two states for two peoples’ this afternoon. In fact, I have never heard you say the phrase ‘two states for two peoples’ because the Palestinian leadership has never recognized that Israel is the nation-state of the Jewish people.”

The Israelis also say that the fact that Mr. Abbas is not welcome in Gaza, the Palestinian coastal enclave run by Hamas, from which he was ejected five years ago, shows that there is no viable Palestinian leadership living up to its obligations now.

Jennifer Steinhauer contributed reporting from Washington, Isabel Kershner from Jerusalem, and Khaled Abu Aker from Ramallah, West Bank.

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The Next War: In Federal Budget Cutting, F-35 Fighter Jet Is at Risk

Luke Sharrett for The New York Times

Vice Adm. David Venlet was named to lead the Joint Strike Fighter program in 2010 after problems had left it behind schedule and over budget.

LEXINGTON PARK, Md. — The Marine version of the F-35 Joint Strike Fighter, already more than a decade in the making, was facing a crucial question: Could the jet, which can soar well past the speed of sound, land at sea like a helicopter?

Luke Sharrett for The New York Times

An F-35B, the Marine Corps version of the Joint Strike Fighter.

On an October day last year, with Lt. Col. Fred Schenk at the controls, the plane glided toward a ship off the Atlantic coast and then, its engine rotating straight down, descended gently to the deck at seven feet a second.

There were cheers from the ship’s crew members, who “were all shaking my hands and smiling,” Colonel Schenk recalled.

The smooth landing helped save that model and breathed new life into the huge F-35 program, the most expensive weapons system in military history. But while Pentagon officials now say that the program is making progress, it begins its 12th year in development years behind schedule, troubled with technological flaws and facing concerns about its relatively short flight range as possible threats grow from Asia.

With a record price tag — potentially in the hundreds of billions of dollars — the jet is likely to become a target for budget cutters. Reining in military spending is on the table as President Obama and Republican leaders in Congress look for ways to avert a fiscal crisis. But no matter what kind of deal is reached in the next few weeks, military analysts expect the Pentagon budget to decline in the next decade as the war in Afghanistan ends and the military is required to do its part to reduce the federal debt.

Behind the scenes, the Pentagon and the F-35’s main contractor, Lockheed Martin, are engaged in a conflict of their own over the costs. The relationship “is the worst I’ve ever seen, and I’ve been in some bad ones,” Maj. Gen. Christopher Bogdan of the Air Force, a top program official, said in September. “I guarantee you: we will not succeed on this if we do not get past that.”

In a battle that is being fought on other military programs as well, the Pentagon has been pushing Lockheed to cut costs much faster while the company is fighting to hold onto a profit. “Lockheed has seemed to be focused on short-term business goals,” Frank Kendall, the Pentagon’s top weapons buyer, said this month. “And we’d like to see them focus more on execution of the program and successful delivery of the product.”

The F-35 was conceived as the Pentagon’s silver bullet in the sky — a state-of-the art aircraft that could be adapted to three branches of the military, with advances that would easily overcome the defenses of most foes. The radar-evading jets would not only dodge sophisticated antiaircraft missiles, but they would also give pilots a better picture of enemy threats while enabling allies, who want the planes, too, to fight more closely with American forces.

But the ambitious aircraft instead illustrates how the Pentagon can let huge and complex programs veer out of control and then have a hard time reining them in. The program nearly doubled in cost as Lockheed and the military’s own bureaucracy failed to deliver on the most basic promise of a three-in-one jet that would save taxpayers money and be served up speedily.

Lockheed has delivered 41 planes so far for testing and initial training, and Pentagon leaders are slowing purchases of the F-35 to fix the latest technical problems and reduce the immediate costs. A helmet for pilots that projects targeting data onto its visor is too jittery to count on. The tail-hook on the Navy jet has had trouble catching the arresting cable, meaning that version cannot yet land on carriers. And writing and testing the millions of lines of software needed by the jets is so daunting that General Bogdan said, “It scares the heck out of me.”

With all the delays — full production is not expected until 2019 — the military has spent billions to extend the lives of older fighters and buy more of them to fill the gap. At the same time, the cost to build each F-35 has risen to an average of $137 million from $69 million in 2001.

The jets would cost taxpayers $396 billion, including research and development, if the Pentagon sticks to its plan to build 2,443 by the late 2030s. That would be nearly four times as much as any other weapons system and two-thirds of the $589 billion the United States has spent on the war in Afghanistan. The military is also desperately trying to figure out how to reduce the long-term costs of operating the planes, now projected at $1.1 trillion.

“The plane is unaffordable,” said Winslow T. Wheeler, an analyst at the Project on Government Oversight, a nonprofit group in Washington.

Todd Harrison, an analyst at the Center for Strategic and Budgetary Assessments, a research group in Washington, said Pentagon officials had little choice but to push ahead, especially after already spending $65 billion on the fighter. “It is simultaneously too big to fail and too big to succeed,” he said. “The bottom line here is that they’ve crammed too much into the program. They were asking one fighter to do three different jobs, and they basically ended up with three different fighters.”

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Recipes for Health: Roasted Sweet Potato and Crispy Kale Salad — Recipes for Health

Andrew Scrivani for The New York Times

This is a great salad to make with leftover roasted sweet potatoes but you can also roast them just to make the salad. The trick to succeeding with crispy kale is to make sure it is completely dry before you put it in the oven. If you are using bunched kale I recommend that you stem and wash it, spin it twice in a salad spinner, then set the leaves in single layers on a few layers of paper towels and roll them up. You can then refrigerate for up to a day or two. Once the salad is assembled, the portion of kale that you toss with the sweet potatoes will soften, and the kale that surrounds the sweet potatoes will remain crispy.

2 large or 3 medium sweet potatoes

1 generous bunch curly kale (about 1 pound), stemmed, leaves washed and dried thoroughly (see above)

2 tablespoons extra virgin olive oil

Salt to taste

1/4 cup broken pecans, lightly toasted

For the dressing:

1 small garlic clove, pureed

2 ounces Roquefort or blue cheese, crumbled

1 teaspoon chopped fresh thyme leaves

1/2 cup buttermilk

1 tablespoon sherry vinegar

Freshly ground pepper

1. To roast the sweet potatoes, heat the oven to 425 degrees. Rinse the sweet potatoes and pierce in several places with the tip of a paring knife. Line a sheet pan with foil and place the sweet potatoes on the foil. Bake 40 to minutes to an hour, depending on the size of the sweet potatoes. They are done when they are soft and beginning to ooze. Remove from heat and allow to cool.

2. Meanwhile make the dressing (or you can make it a day ahead). In a mini-processor or in a mortar and pestle blend together the garlic, cheese, thyme, buttermilk, and vinegar. Season to taste with salt and pepper. For best results, leave it to sit for at least an hour.

3. To make the crispy kale, heat the oven to 300 degrees. Line two baking sheets with parchment. Make sure that your kale leaves are dry and tear them into medium-size pieces and toss with the olive oil. Gently knead the leaves between your thumbs and fingers to make sure they are coated with oil. Place in an even layer on the baking sheets. Do this in batches if necessary. Place in the oven and roast for 16 to 22 minutes, until the leaves are crisp but not browned. If some of the leaves crisp before others, remove them to a bowl or sheet pan and return the remaining kale to the oven. Watch closely as once the kale browns it will taste bitter. Season to taste with kosher salt or fine sea salt. Allow to cool.

4. Peel the sweet potatoes, quarter lengthwise and slice. Place in a salad bowl and add the pecans and half the crispy kale.

5. Line the edge of a platter with the remaining crispy kale. Toss the sweet potato mixture with the dressing, place in the middle of the platter and serve at once.

Yield: Serves 4 as a main dish

Advance preparation: The crispy kale will remain crisp for a day at room temperature. Sweet potatoes can be baked and refrigerated for up to four days. The salad should be served right away once assembled.

Nutritional information per serving: 378 calories; 17 grams fat; 4 grams saturated fat; 3 grams polyunsaturated fat; 9 grams monounsaturated fat; 14 milligrams cholesterol; 49 grams carbohydrates; 8 grams dietary fiber; 431 milligrams sodium (does not include salt to taste); 11 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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Recipes for Health: Roasted Sweet Potato and Crispy Kale Salad — Recipes for Health

Andrew Scrivani for The New York Times

This is a great salad to make with leftover roasted sweet potatoes but you can also roast them just to make the salad. The trick to succeeding with crispy kale is to make sure it is completely dry before you put it in the oven. If you are using bunched kale I recommend that you stem and wash it, spin it twice in a salad spinner, then set the leaves in single layers on a few layers of paper towels and roll them up. You can then refrigerate for up to a day or two. Once the salad is assembled, the portion of kale that you toss with the sweet potatoes will soften, and the kale that surrounds the sweet potatoes will remain crispy.

2 large or 3 medium sweet potatoes

1 generous bunch curly kale (about 1 pound), stemmed, leaves washed and dried thoroughly (see above)

2 tablespoons extra virgin olive oil

Salt to taste

1/4 cup broken pecans, lightly toasted

For the dressing:

1 small garlic clove, pureed

2 ounces Roquefort or blue cheese, crumbled

1 teaspoon chopped fresh thyme leaves

1/2 cup buttermilk

1 tablespoon sherry vinegar

Freshly ground pepper

1. To roast the sweet potatoes, heat the oven to 425 degrees. Rinse the sweet potatoes and pierce in several places with the tip of a paring knife. Line a sheet pan with foil and place the sweet potatoes on the foil. Bake 40 to minutes to an hour, depending on the size of the sweet potatoes. They are done when they are soft and beginning to ooze. Remove from heat and allow to cool.

2. Meanwhile make the dressing (or you can make it a day ahead). In a mini-processor or in a mortar and pestle blend together the garlic, cheese, thyme, buttermilk, and vinegar. Season to taste with salt and pepper. For best results, leave it to sit for at least an hour.

3. To make the crispy kale, heat the oven to 300 degrees. Line two baking sheets with parchment. Make sure that your kale leaves are dry and tear them into medium-size pieces and toss with the olive oil. Gently knead the leaves between your thumbs and fingers to make sure they are coated with oil. Place in an even layer on the baking sheets. Do this in batches if necessary. Place in the oven and roast for 16 to 22 minutes, until the leaves are crisp but not browned. If some of the leaves crisp before others, remove them to a bowl or sheet pan and return the remaining kale to the oven. Watch closely as once the kale browns it will taste bitter. Season to taste with kosher salt or fine sea salt. Allow to cool.

4. Peel the sweet potatoes, quarter lengthwise and slice. Place in a salad bowl and add the pecans and half the crispy kale.

5. Line the edge of a platter with the remaining crispy kale. Toss the sweet potato mixture with the dressing, place in the middle of the platter and serve at once.

Yield: Serves 4 as a main dish

Advance preparation: The crispy kale will remain crisp for a day at room temperature. Sweet potatoes can be baked and refrigerated for up to four days. The salad should be served right away once assembled.

Nutritional information per serving: 378 calories; 17 grams fat; 4 grams saturated fat; 3 grams polyunsaturated fat; 9 grams monounsaturated fat; 14 milligrams cholesterol; 49 grams carbohydrates; 8 grams dietary fiber; 431 milligrams sodium (does not include salt to taste); 11 grams protein

Martha Rose Shulman is the author of “The Very Best of Recipes for Health.”

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Google Fires a Rare Public Salvo Over Aggregators

BERLIN — Google’s imprint on daily life is hard to ignore in Europe, where it reportedly has 93 percent of the Internet search market, more than in the United States. Yet when it comes to its lobbying of lawmakers, Google prefers a low profile.

That all changed this week when Google fired a rare public broadside against a proposal that would force it and other online aggregators of news content to pay German newspaper and magazine publishers to display snippets of news in Web searches.

The proposed ancillary copyright law, which is to have its first reading Friday in the lower house of Parliament, the Bundestag, has ignited a storm of hyperbole pitting Google and local Web advocates against powerful publishers including Süddeutsche Zeitung, Frankfurter Allgemeine Zeitung, Bild and Die Welt.

Google took off the gloves Tuesday when it opened a campaign urging German users to e-mail members of the Bundestag with their concerns. Google said the proposal would shrink the free flow of information on the Internet in Germany, perhaps even forcing it to display blank links to German references.

The issue is also being debated in other European capitals. In October, President François Hollande of France asked the Google executive chairman, Eric Schmidt, to have a representative meet with a government mediator to resolve the issue. The company complied. The implicit threat was that if no solution were found, France might pursue a legislative option.

Christoph Keese, the senior vice president of Axel Springer, publisher of Bild and Die Welt, two of the largest-circulation newspapers in Germany, said lawmakers in Italy, Switzerland, Austria, Portugal and Spain were considering similar measures. Google said that conversely, new laws passed in Canada, and proposals that could soon be adopted in Britain and the Netherlands, would further loosen copyright restrictions and free up new kinds of Internet sharing.

The German proposal “would make it much more difficult to find the information that you seek in the Internet,” Google warned in its campaign, which it titled “Defend Your Internet.”

The unusually public salvos from Google caught many German lawmakers by surprise. Chancellor Angela Merkel raised the issue at a working dinner Tuesday with a group of lawmakers from her party, the Christian Democratic Union, including Peter Beyer, a member of the Bundestag from Ratingen, a town near Düsseldorf.

“She asked us how many e-mails we’d received and we told her,” he said Wednesday during an interview, adding that he had received fewer than 10 from Google supporters. “Most of us had only received a few, three or four. She and the rest of the C.D.U. are still behind this law. I have no doubts that it will pass.”

That may not be as simple as supporters envision.

Germany’s main technology industry association, the Federal Association for Information Technology, Telecommunications and New Media, known as BitKom, has come out sharply against the proposal, saying it will curb investment in the German digital economy.

“They are planning a law that would be unique worldwide, which would send a negative signal to investors: Innovative online services are not desired in Germany,” said Bernhard Rohleder, chief executive of BitKom.

A letter to Bundestag members signed jointly by 16 copyright law professors, the Max Planck Institute for Intellectual Property and Competition Law, and Grur, an association representing 5,300 German copyright lawyers, warned that the law could cost Germany jobs. “There is a danger that this law will have unforeseen negative consequences,” the letter read.

By midday Wednesday, one day into the campaign, Google said that 25,000 people had signed its petition and that it expected a half-million people to have viewed its Web site.

The showdown being played out in Berlin may not be resolved by lawmakers until early next year. But it stems from a long-running dispute between Google and German newspaper and magazine publishers that dates from 2007, said Anja Pasquay, a spokeswoman for the German Association of Newspaper Publishers.

That was when publishers first decided to pursue a legislative solution after failing to persuade Google to sit down and negotiate a licensing agreement for the industry, Ms. Pasquay said.

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