President Obama Asks Congress to Keep Tax Cuts for Middle Class

Doug Mills/The New York Times

President Obama spoke on Wednesday at an event at the White House with people who would see their taxes go up next year if Congress does not extend tax cuts for the middle class.

WASHINGTON — President Obama called again on Congress on Wednesday to extend Bush-era tax cuts for all income under $250,000 and leave a broader restructuring of the tax code to next year, as he pressures Republicans to let tax rates rise for the wealthiest Americans.

Surrounding himself by supporters he presented as typical middle-class taxpayers, Mr. Obama said he hoped to resolve the tax and spending issues now confronting Washington by an end-of-the-year deadline. But he said lawmakers should not wait for such an agreement to pass legislation preserving current tax rates for 98 percent of Americans.

“My hope is to get this done before Christmas,” he said of an agreement to avert deep spending cuts and tax increases scheduled to take place automatically with the new year. “But the place where we already have in theory at least complete agreement right now is on middle-class taxes.”

He said such an approach “would give us more time next year to work together on a comprehensive plan to bring down our deficits” and “streamline our tax system.”

The administration planned to send a high-level delegation to Capitol Hill to talk through the situation. Treasury Secretary Timothy F. Geithner and Rob Nabors, the White House legislative affairs director, will visit, separately, the top leaders of both parties in both houses, an administration official said.

Republicans in Congress have resisted letting the Bush tax cuts expire for anyone, including the wealthy. But Representative Tom Cole, an Oklahoma lawmaker and a highly regarded party political strategist, broke with his party leadership on Tuesday by calling for a quick deal with Mr. Obama on extending the tax cuts just for the middle class.

Mr. Obama seemed to refer to that during his event in the office building adjacent to the White House. “I’m glad to see if you’ve been reading the papers lately that more and more Republicans in Congress seem to be agreeing with this idea that we should have a balanced approach,” he said.

But a prominent figure in the fiscal discussions expressed pessimism that the two sides would be able to reach an agreement to avert what is being called a fiscal cliff.

“I believe the probability is that we are going over the cliff, and I think that we will be horrible,” Erskine B. Bowles, a former White House chief of staff who served as co-chairman of Mr. Obama’s deficit reduction commission, told reporters at a breakfast hosted by The Christian Science Monitor. “It will be devastating to the economy.”

The president’s appearance with taxpayers was part of a week of campaign-style events staged by the White House to rally public support for its side in the fiscal fight. He planned to meet with 14 chief executives of corporations at the White House later in the day and travel to the Philadelphia suburbs to tour a factory on Friday.

Republicans have said Mr. Obama seems more interested in perpetuating his campaign than in sitting down to hash out the difficult issues. They also note that they have expressed a willingness to raise tax revenue by closing loopholes and limiting deductions, but they have complained that Mr. Obama has not focused as much on the spending side of the equation, particularly entitlement programs like Medicare and Medicaid.

“We have not seen any good-faith effort on the part of this administration to talk about the real problem that we’re trying to fix,” Representative Eric Cantor of Virginia, the House Republican majority leader, told reporters on Wednesday. “This has to be a part of this agreement, or else we just continue to dig the hole deeper, asking folks to allow us to kick the can down the road further. And that we don’t want to do.”

Speaker John A. Boehner of Ohio echoed that argument but expressed hope that he could reach an agreement with Mr. Obama. “It’s time for the president and Democrats to get serious about the spending problem that our country has,” he said at a news conference. “But I’m optimistic that we can continue to work together to avert this crisis, and sooner rather than later.”

But some Republicans were beginning to make the argument that extending the Bush tax cuts for 98 percent of Americans would still be a victory for their party and a validation of the former president.

Senator Patty Murray of Washington, the Democratic chairwoman of the Budget Committee, said the talk was encouraging. “This has never been about partisanship or political point-scoring,” she said. “It’s been about protecting the middle class from paying more in taxes and calling on the wealthy to pay their fair share.”

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Protesters Gather Again in Cairo Streets to Denounce Morsi

CAIRO — Thousands of people flowed into the streets of Cairo, the Egyptian capital, Tuesday afternoon for a day of protest against President Mohamed Morsi’s attempt to assert broad new powers for the duration of the country’s political transition, dismissing his efforts just the night before to reaffirm his deference to Egyptian law and courts.

By early Tuesday afternoon in Cairo, a dense crowd of hundreds had gathered outside the headquarters of a trade group for lawyers, and thousands more had filed in around a small tent city in Tahrir Square. In an echo of the chants against Hosni Mubarak, Egyptian’s ousted president, almost two years ago, they shouted, “Leave, leave!” and “Bring down the regime!” They also denounced the spiritual leader of the Muslim Brotherhood, the Islamist group allied with Mr. Morsi.

A few blocks away, in a square near the American Embassy and the Interior Ministry headquarters, groups of young men resumed a running battle that began nine days ago, throwing rocks and tear gas canisters at riot police officers. Although those clashes grew out of anger over the deaths of dozens of protesters in similar clashes one year ago, many of the combatants have happily adopted the banner of protest against Mr. Morsi as well.

Egyptian television had captured the growing polarization of the country on Monday in split-screen coverage of two simultaneous funerals, each for a teenage boy killed in clashes set off by disputes over the new president’s powers. Thousands of supporters of Mr. Morsi and his allies in the Muslim Brotherhood marched through the streets of the Nile Delta city of Damanhour to bury a 15-year-old killed outside a Brotherhood office during an attack by protesters. And in Tahrir Square here in Cairo, thousands gathered to bury a 16-year-old killed in clashes with riot police officers and to chant slogans blaming Mr. Morsi for his death. “Morsi killed him,” the boy’s father said in a video statement circulated over the Internet.

“Now blood has been spilled by political factions, so this is not going to go away,” said Rabab el-Mahdi, a professor at the American University in Cairo and a left-leaning activist, adding that these were the first deaths rival factions had blamed on each other and not on the security forces of the Mubarak government since the uprising began last year. Still larger crowds were expected in the evening, as marchers from around the city headed for the square. Many schools and other businesses had closed in anticipation of bedlam, and on Monday, the Brotherhood called off a rival demonstration in support of the president, saying it wanted to avoid violence.

Egypt’s Supreme Judicial Council met again on Tuesday to consider its response to the president, and the leader of Al Azhar, a center of Sunni Muslim learning that is regarded as the pre-eminent moral authority here, met with groups of political leaders in an effort to resolve the battle over the president’s decree and the deadlock in the constitutional assembly, which is trying to draw up a new constitution.

But even as Mr. Morsi met with top judges Monday night in an effort to resolve the crisis, a coalition of opposition leaders held a news conference to declare that preserving the role of the courts was only the first step in a broader campaign against what Abdel Haleem Qandeil, a liberal intellectual, called “the miserable failure of the rule of the Muslim Brothers.” Mr. Morsi “unilaterally broke the contract with the people,” he declared. “We have to be ready to stand up to this group, protest to protest, square to square, and to confront the bullying.”

Mr. Morsi’s effort to remove the last check on his power over the political transition had brought the country’s fractious opposition groups together for the first time in a united front against the Brotherhood. But the show of unity papered over deep divisions between groups and even within them, said Ms. Mahdi of the American University.

“This is not a united front, and I am inside it,” she said. “Every single political group in the country is now divided over this — is this decree revolutionary justice or building a new dictatorship? Should we align ourselves with folool” — the colloquial term for the remnants of the old political elite — “or should we be revolutionary purists? Is it a conflict between the Muslim Brotherhood and the pro-Mubarak judiciary, or is this the beginning of a fascist regime in the making?”

Mayy El Sheikh contributed reporting.

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Eagles lose receiver DeSean Jackson to injury

PHILADELPHIA (AP) — The Philadelphia Eagles will place wide receiver DeSean Jackson on injured reserve after he sustained multiple rib fractures in Monday night's loss to Carolina.

Jackson leads the team with 45 catches and 700 yards receiving, but has only two touchdowns. Coach Andy Reid says the injury could take six weeks to heal.

Reid says running back LeSean McCoy remains in phase one of his concussion recovery and Michael Vick is in the fourth of five stages. Vick has missed the last two games and McCoy didn't play against the Panthers.

Defensive tackle Fletcher Cox injured his tailbone and offensive lineman King Dunlap sprained his knee. Neither will practice Wednesday.

The Eagles (3-8) have lost seven straight games. They'll visit Dallas (5-6) next Sunday night.

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

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Amid Hurricane Sandy, a Race to Get a Liver Transplant

It was the best possible news, at the worst possible time.

The phone call from the hospital brought the message that Dolores and Vin Dreeland had long hoped for, ever since their daughter Natalia, 4, had been put on the waiting list for a liver transplant. The time had come.

They bundled her into the car for the 50-mile trip from their home in Long Valley, N.J., to NewYork-Presbyterian Morgan Stanley Children’s Hospital in Manhattan. But it soon seemed that this chance to save Natalia’s life might be just out of reach.

The date was Sunday, Oct. 28, and Hurricane Sandy, the worst storm to hit the East Coast in decades, was bearing down on New York. Airports and bridges would soon close, but the donated organ was in Nevada, five hours away. The time window in which a plane carrying the liver would be able to land in the region was rapidly closing.

In a hospital room, Natalia watched cartoons. Her parents watched the clock, and the weather. “Our anxiety was through the roof,” Mrs. Dreeland said. “It just made your stomach into knots.”

The Dreelands, who are in their 60s, became Natalia’s foster parents in 2008 when she was 7 months old, and adopted her just before she turned 2. They have another adopted daughter, Dorothy Jane, who is 17.

Natalia is a “smart little cookie” who loves school and dressing up Alice, her favorite doll, her mother said. At age 3, Natalia used the word “discombobulated” correctly, Mr. Dreeland said.

Natalia’s health problems date back several years. Her gallbladder was taken out in 2010, and about half her liver was removed in 2011. The underlying problem was a rare disease, Langerhans cell histiocytosis. It causes a tremendous overgrowth of a type of cell in the immune system and can damage organs. Drugs can sometimes keep it in check, but they did not work for Natalia.

In her case, the disease struck the bile ducts, which led to progressive liver damage. “She would have eventually gone into liver failure,” said Dr. Nadia Ovchinsky, a pediatric liver transplant specialist at NewYork-Presbyterian. “And she demonstrated some signs of early liver failure.”

The only hope was a transplant.

Dr. Tomoaki Kato, Natalia’s surgeon, knew that the liver in Nevada was a perfect match for Natalia in the two criteria that matter most: blood type and size. The deceased donor was 2 years old, and though Natalia is nearly 5, she is small for her age. Scar tissue from her previous operations would have made it very difficult to fit a larger organ into her abdomen.

Though Dr. Kato had considered transplanting part of an adult liver into Natalia, a complete organ from a child would be far better for her. But healthy organs from small children do not often become available, Dr. Kato said. This was a rare opportunity, and he was determined to seize it.

But as the day wore on, the odds for Natalia grew slimmer. The operation in Nevada to remove the liver was delayed several times.

At many hospitals, surgery to remove donor organs is done at the end of the day, after all regularly scheduled operations. The Nevada hospital had a busy surgical schedule that day, made worse by a trauma case that took priority.

At the hospital in New York, Tod Brown, an organ procurement coordinator, had alerted a charter air carrier that a flight from Nevada might be needed. That company in turn contacted West Coast carriers to pick up the donated liver and fly it to New York.

Initially, two carriers agreed, but then backed out. Several other charter companies also declined.

Mr. Brown told Dr. Kato that they might have to decline the organ. Dr. Kato, soft-spoken but relentless, said, “Find somebody who can fly.”

Dr. Kato used to work in Miami, where pilots found ways to bypass hurricanes to deliver organs. Even during Hurricane Katrina, his hospital performed transplants.

“I asked the transplant coordinators to just keep pushing,” he said.

Mr. Brown said, “Dr. Kato knew he was going to get that organ, one way or another.”

As the trajectory of the storm became clearer, one of the West Coast charter companies agreed to attempt the flight. The plan was to land at the airport in Teterboro, N.J. The backup was Newark airport, and the second backup was Albany, from where an ambulance would finish the trip.

The timing was critical: organs deteriorate outside the body, and ideally a liver should be transplanted within 12 hours of being removed.

Early Monday, as the storm whirled offshore, the plane landed at Teterboro. Soon a nurse rushed to tell the Dreelands that she had just seen an ambulance with lights and sirens screech up to the hospital. Someone had jumped out carrying a container.

At about 5 a.m., the couple kissed Natalia and saw her wheeled off to the operating room.

Three weeks later, she is back home, on the mend. The complicated regimen of drugs that transplant patients need is tough on a child, but she is getting through it, her father said.

Recently, Mr. Dreeland said, he found himself weeping uncontrollably during a church service for the family of the child who had died. “Their child gave my child life,” he said.

Though only time will tell, because the histiocytosis appeared limited to Natalia’s bile ducts and had not affected other organs, her doctors say there is a good chance that the transplant has cured her.

This article has been revised to reflect the following correction:

Correction: November 27, 2012

An earlier version of a picture caption with this article misspelled the surname of the family whose daughter received a liver transplant. As the article correctly noted elsewhere, it is Dreeland, not Vreeland.

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Dark Warnings About Future of Internet Access

PARIS — Every time an Internet user watches “Gangnam Style” on YouTube, packets of digital data course through the global telecommunications system, converging on an iPhone, a tablet or a laptop.

Having missed out on most of the lucrative revenue that the explosion of digital content has generated for Internet companies, telecommunications providers in Europe, Africa, the Middle East and elsewhere now want to charge them for carrying this traffic.

No way, the content providers say.

This commercial and ideological clash is set for a showdown next week, when representatives of more than 190 governments, along with telecommunications companies and Internet groups, gather in Dubai for a once-in-a-generation meeting.

The ostensible purpose of the World Conference on International Telecommunications is to update a global treaty on technical standards needed to, say, connect a telephone call from Tokyo to Timbuktu. The previous conference took place in 1988, when the Internet was in its infancy and telecommunications remained a highly regulated, mostly analog business.

Critics of the International Telecommunication Union, the United Nations’ agency that is organizing the meeting, see a darker agenda. The blogosphere has been raging over supposed plans led by Russia to snatch away control of the Internet and hand it to the U.N. agency.

That seems unlikely. Any such move would require an international consensus, and opposition is widespread. Terry Kramer, the U.S. ambassador to the conference, has vowed to veto any change in how the Internet is overseen.

Hamadoun Touré, secretary general of the telecommunications union, has repeatedly said that it has no desire to take over the Internet or to stifle its growth. On the contrary, he says, one of the main objectives of the conference is to spread Internet access to more of the four and a half billion people around the world who still do not use it.

And yet, groups as diverse as Google, the Internet Society, the International Trade Union Confederation and Greenpeace warn that the discussions could set a bad precedent, encouraging governments to step up censorship or take other actions that would threaten the integrity of the Internet.

“This is a very important moment in the history of the Internet, because this conference may introduce practices that are inimical to its continued growth and openness,” Vinton G. Cerf, vice president and chief Internet evangelist at Google, said during a conference call.

Google set up a Web site last week, “Take Action,” encouraging visitors to sign a petition for a “free and open Internet.” The campaign is modeled on the successful drive last winter to defeat legislative proposals to crack down on Internet piracy in the United States.

Analysts say the outcry over censorship and Internet governance is a red herring; the real business of the conference is business.

“The far bigger issue — largely obscured by this discussion — are proposals that are more likely to succeed that envision changing the way we pay for Internet services,” Michael Geist, an Internet law professor at the University of Ottawa, said by e-mail.

In one submission to the conference, the European Telecommunications Network Operators’ Association, a lobbying group based in Brussels that represents companies like France Télécom, Deutsche Telekom and Telecom Italia, proposed that network operators be permitted to assess charges for content providers like Internet video companies that use a lot of bandwidth.

Analysts say the proposal is an acknowledgment by telecommunications companies that they cannot compete in the provision of digital content.

“The telecoms realize that they have lost the battle,” said Paul Budde, an independent telecommunications analyst in Australia. “They are saying, ‘We can’t beat the Googles and the Facebooks, so let’s try to charge them.”’

The European lobbying group says that without the new fees, there will be no money to invest in the network upgrades needed to deal with a surge in traffic. Regulators have required European telecommunications operators to open their networks to rivals, and the market for broadband is fiercely competitive, with rock-bottom prices.

In the United States, by contrast, most telecommunications companies have been permitted to maintain local monopolies — or duopolies, with cable companies — in broadband, keeping prices higher. And U.S. regulators have ordered broadband providers to give equal priority to all Internet traffic. Such “network neutrality” is incompatible with charging content providers for carriage.

Analysts say this may explain why U.S. telecommunications companies have not joined the European call for a new business model.

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Egypt’s President Said to Limit Scope of Judicial Decree

CAIRO — President Mohamed Morsi agreed Monday to scale back a sweeping decree he had issued last week that raised his edicts above any judicial review, according to a report by a television network allied with his party. The agreement, reached with top judicial authorities, would leave most of Mr. Morsi’s actions subject to review by the courts, but preserve a crucial power: protecting the constitutional council from being dissolved by the courts before it finishes its work.

Ahmed Jadallah/Reuters

Protesters ran for cover during clashes with riot police at Tahrir square in Cairo on Monday.

Tara Todras-Whitehill for The New York Times

Egyptians mourned Mohammed Gaber Salah, an activist who died Sunday from injuries sustained during protests, before his funeral on Monday in Cairo.

The Muslim Brotherhood, the Islamist group that sponsored Mr. Morsi and his party, announced that it was canceling a major demonstration in support of the president that had been planned for Tuesday.

Cracks appeared in Mr. Morsi’s government on Sunday over the decree after the justice minister, Ahmed Mekki, began arguing publicly for a retreat, and at least three other senior advisers resigned over the measure. The move had also prompted widening street protests and cries from opponents that Mr. Morsi, who already governs without a legislature, was moving toward a new autocracy in Egypt, less than two years after the ouster of the strongman Hosni Mubarak.

With a threatened strike by the nation’s judges, a plunge in the country’s stock market and more street protests looming, Mr. Morsi’s administration initially sent mixed messages on Sunday over whether it was willing to consider a compromise: a spokesman for the president’s party insisted that there would be no change in his edict, but a statement from the party indicated for the first time a willingness to give political opponents “guarantees against monopolizing the fateful decisions of the homeland in the absence of the Parliament.”

Mr. Mekki, the influential leader of a judicial independent movement under Mr. Mubarak and one of Mr. Morsi’s closest aides, actively tried to broker a deal with top jurists to resolve the crisis.

The reaction to the decree had presented the most acute test to date of the ability and willingness of Mr. Morsi, Egypt’s first freely elected president and a former leader of the Muslim Brotherhood, to engage in the kind of give and take that democratic government requires. But he also must contend with real doubts about the willingness of his anti-Islamist opponents to join him in compromise. Each side is mired in deep suspicion of the other, a legacy of the decades when the Brotherhood survived here only as an insular secret society, demonized as dangerous radicals by most of the Egyptian elite.

“There is a deep mistrust,” said Emad Shahin, a political scientist at the American University in Cairo who studies the Brotherhood. “It is an ugly round of partisan politics,” he said, “a bone-crushing phase.”

The scale of the backlash against the decree appeared to catch Mr. Morsi’s government by surprise. “In his head, the president thought that this would push us forward, but then it was met with all this inflammation,” Mr. Mekki said. He faulted the president for failing to consult with his opponents before issuing it, but he also faulted the opponents for their own unwillingness to come to the table: “I blame all of Egypt, because they do not know how to talk to each other.”

Government and party officials maintained that Mr. Morsi was forced to claim the expansive new powers to protect the process of writing the country’s new constitution, and that the decree would be in effect only until the charter was in place. A court of judges appointed under the Mubarak government was widely rumored to be about to dissolve the elected constitutional assembly, dominated by Mr. Morsi’s Islamist allies — just as the same court had previously cast out the newly elected Islamist-led Parliament — and the decree issued by Mr. Morsi on Thursday gave him the power to stop it.

“I see with all of you, clearly, that the court verdict is announced two or three weeks before the court session,” Mr. Morsi told his supporters on Friday, referring to the pervasive rumors about the court’s impending action in a fiery speech defending his decree. “We will dissolve the entire homeland, as it seems! How is that? How? Those waywards must be held accountable."

He said that corrupt Mubarak loyalists were “hiding under the cover of the judiciary” and declared, “I will uncover them!”

But instead of rallying the public to his side and speeding the country’s political transition, as Mr. Morsi evidently hoped, his decree has unleashed new instability across the country. On Sunday, the first day of business here since the decree was issued, the Egyptian stock market fell by about 9.5 percent, erasing more than $4 billion of value.

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Longoria agrees to deal adding $100 million

ST. PETERSBURG, Fla. (AP) — Evan Longoria wants to be with the Tampa Bay Rays for his entire big league career.

The slugging third baseman agreed Monday to a 10-year contract that adds six guaranteed seasons and $100 million.

"I always wanted to be kind of a benchmark player ... the guy that you could think about or associate with the organization," Longoria said. "My goal from Day One was to be the first player that played their whole career here, to be the first guy that came into the organization and went out in the organization, and played all the years in between. There's no better place for me."

The agreement with the three-time All-Star incorporates the remainder of the 27-year-old's existing contract, which called for him to earn $36.6 million over the next four seasons. The new deal includes a team option for 2023.

"It's a very exciting day for us," Rays principal owner Stuart Sternberg said. "For Evan to have the confidence in us, and I know the confidence that we have in him, to re-up so to speak for the long haul. This is just an enormous commitment for us."

Longoria said a no-trade provision is not included in the deal, although after 2017 he would have a right to block trades as a 10-year veteran who spent his last five years with the same team.

Just six games into his major league career, Longoria agreed in April 2008 to a $17.5 million, six-year contract that included club options potentially making the deal worth $44 million over nine seasons.

"The significance of this is not lost on anybody," Rays executive vice president of baseball operations Andrew Friedman said. "We're extending that commitment now."

Longoria became just the seventh player with a contract guaranteed through 2020. Milwaukee outfielder Ryan Braun, Detroit first baseman Prince Fielder, Chicago Cubs outfielder Jorge Soler and Colorado shortstop Troy Tulowitzki have deals covering the next eight years, with Los Angeles Angels first baseman Albert Pujols' contract running through 2021 and Cincinnati first baseman Joey Votto's through 2023.

Tampa Bay selected Longoria as the third overall pick in the 2006 amateur draft, making him the first player drafted under Sternberg and Friedman.

Longoria played in just 74 games in 2012 because of a partially torn left hamstring. He underwent a minor surgical cleanup procedure on the hamstring Nov. 20 and is expected to be ready for spring training.

"With the time that we had now, there's no doubt that I'd be able to recover and be at 100 percent or close to it by (the start of) spring training," Longoria said.

Longoria will rehab the leg during the winter and will not participate in next year's World Baseball Classic.

Tampa Bay was 41-44 during Longoria's absence, and 47-27 with him in the starting lineup.

The two-time AL Gold Glove winner and 2008 AL Rookie of the Year ranks second on the Rays career list with 130 home runs, third with 456 RBIs and fourth with 161 doubles. Longoria is one of 11 active players to average at least 25 homers and 90 RBIs during his first five seasons.

Longoria will donate more than $1 million during the contract to the Rays Baseball Foundation, the team's charitable foundation.

Sternberg said this deal does not rule out the possibility of signing other Tampa Bay players to mulityear contracts, such as AL Cy Young Award winner David Price. The Rays were at the bottom of the big leagues in home attendance this year.

"One of the challenges we'll have is figuring out how to take the next step for our organization," Sternberg said.

Tampa Bay and Longoria had brief, preliminary contract talks before the season began and resumed discussions after the season ended.

"We kind of tried to find a middle ground to where we would able to do some things to be able to afford some players to put ourselves in a position to win every year," Longoria said. "And I told them from the beginning that I didn't want to be the one sucking up all the payroll so we can't afford anybody else."

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Hospitals Face Pressure From Medicare to Avert Readmissions

After years of gently prodding hospitals to make sure discharged patients do not need to return, the federal government is now using its financial muscle to discourage readmissions.

Medicare last month began levying financial penalties against 2,217 hospitals it says have had too many readmissions. Of those hospitals, 307 will receive the maximum punishment, a 1 percent reduction in Medicare’s regular payments for every patient over the next year, federal records show.

One of those is Barnes-Jewish Hospital in St. Louis, which will lose $2 million this year. Dr. John Lynch, the chief medical officer, said Barnes-Jewish could absorb that loss this year, but “over time, if the penalties accumulate, it will probably take resources away from other key patient programs.”

The crackdown on readmissions is at the vanguard of the Affordable Care Act’s effort to eliminate unnecessary care and curb Medicare’s growing spending, which reached $556 billion this year. Hospital inpatient costs make up a quarter of that spending and are projected to grow by more than 4 percent annually in coming years, according to the Congressional Budget Office.

The readmission penalties will recoup about $300 million this year. But the goal is to pressure hospitals to pay attention to what happens to their patients after they walk out the door. The penalties have captured the attention of hospitals, and many are trying to improve their supervision of discharged patients’ recoveries.

“I’ve been doing this for over two decades and talking to hospital leaders about readmissions, and I used to get polite but blank stares,” said Dr. Eric Coleman, a professor at the University of Colorado Anschutz Medical Campus who has devised widely adopted methods to reduce hospitalizations. “Now they’re paying attention.”

With nearly one in five Medicare patients returning to the hospital within a month — about two million people a year — readmissions cost the government more than $17 billion annually.

Hospitals’ traditional reluctance to tackle readmissions is rooted in Medicare’s payment system. Medicare generally pays hospitals a set fee for a patient’s stay, so the shorter the visit, the more revenue a hospital can keep. Hospitals also get paid when patients return. Until the new penalties kicked in, hospitals had no incentive to make sure patients didn’t wind up coming back. The maximum penalty is set to double next October and then reach 3 percent of reimbursements in October 2015. Medicare also is expanding the list of conditions it will assess in setting punishments.

Right now it only evaluates readmissions of heart attack, heart failure and pneumonia patients, counting every rebound, even ones not related to the original reason for hospitalization. The penalties are based on readmission rates in the past and applied to future payments for all Medicare patients.

Researchers say that while some readmissions are unavoidable, many are caused by the short shrift hospitals have given patients on their way out.

Jonathan Blum, principal deputy administrator for the Centers for Medicare and Medicaid Services, said the penalties had helped galvanize hospitals’ efforts to avoid readmissions. “We’ve seen a small but significant reduction,” he said. “That tells me we’ve focused the industry on improvement.”

Medicare’s tough love is not going over well everywhere. Academic medical centers are complaining that the penalties do not take into account the extra challenges posed by extremely sick and low-income patients. For these people, getting medicine and follow-up care can be a struggle.

At Barnes-Jewish Hospital, Dr. Lynch said physicians from all over the Midwest referred their sickest heart patients to his facility for transplants and other major interventions. But those patients can skew his hospital’s readmissions numbers, he said: “The weaker your heart, the more advanced your emphysema, the more likely you are to be readmitted to the hospital.”

Dr. Lynch said Barnes-Jewish set up follow-up appointments for patients who didn’t have their own doctors. But about half of the patients never showed up, he said, even after the hospital made reminder phone calls and arranged for free rides. Sending nurses to see patients at home did not significantly reduce readmission rates either, he said.

“Many of us have been working on this for other reasons than a penalty for many years, and we’ve found it’s very hard to move,” Dr. Lynch said. He said the penalties were unfair to hospitals with the double burden of caring for very sick and very poor patients.

“For us, it’s not a readmissions penalty,” he said. “It’s a mission penalty.”

Various studies, including one commissioned by Medicare, have found that the hospitals with the most poor and African-American patients tended to have higher readmission rates than hospitals with more affluent and Caucasian patients. But the studies also determined that some safety-net hospitals performed better than average, showing that hospitals can overcome the challenges posed by the kinds of patients they treat.

In some ways, the debate parallels the one on education — specifically, whether educators should be held accountable for lower rates of progress among children from poor families.

“Just blaming the patients or saying ‘it’s destiny’ or ‘we can’t do any better’ is a premature conclusion and is likely to be wrong,” said Dr. Harlan Krumholz, director of the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital, which prepared the study for Medicare. “I’ve got to believe we can do much, much better.”

Some researchers fear the Medicare penalties are so steep, they will distract hospitals from other pressing issues, like reducing infections and surgical mistakes and ensuring patients’ needs are met promptly. “It should not be our top priority,” said Dr. Ashish Jha, a professor at the Harvard School of Public Health who has studied readmissions. “If you think of all the things in the Affordable Care Act, this is the one that has the biggest penalties, and that’s just crazy.”

With pressure to avert readmissions rising, some hospitals have been suspected of sending patients home within 24 hours, so they can bill for the services but not have the stay counted as an admission. But most hospitals are scrambling to reduce the number of repeat patients, with mixed success.

A few days after Eda Laurion was discharged from the Banner Del E. Webb Medical Center near Phoenix after treatment for her congestive heart failure in August, a nurse showed up at her house.

“She helped explained the medicines I’m taking, the side effects, what they do for you,” said Ms. Laurion, 91, of Sun City West.

Still, readmissions can’t always be prevented. The nurse, Sue Koner, sent Ms. Laurion back to the hospital after two weeks for dangerously low sodium caused by an undiagnosed kidney problem. However, Ms. Laurion avoided re-hospitalization in October when Ms. Koner deduced that her hallucinations were a reaction to an antibiotic.

Overseeing former patients is expensive and time-consuming, so many hospitals are relying on financing from community health organizations and foundations. Ms. Koner works for Sun Health, a foundation-supported nonprofit. Since Sun Health started its program in November 2011, only nine of 213 patients have been readmitted.

Dr. Krumholz said hospitals should think of readmissions as a challenge to overcome. “One day, we’ll look back,” he said, “and we’ll be incredulous that one out of every five patients ended up back in the hospital.”

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

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DealBook: Mortgage Interest Deduction Is Now Seen as Vulnerable

A tax break that has long been untouchable could soon be in for some serious manhandling.

Many home buyers deduct their mortgage interest when assessing their tax bill, a perk that has helped bolster the income of millions of families — and the broader housing market.

But as President Obama and Congress try to hash out a deal to reduce the budget deficit, the mortgage interest deduction looks vulnerable. Limits on a broad array of deductions could emerge in any budget deal. It is likely that any caps would be structured to aim at high-income households, and would diminish or end the mortgage tax break for many of those taxpayers.

“This is definitely a chance worth jumping for,” said Amir Sufi, a professor at the Booth School of Business at the University of Chicago. “For a fixed amount of revenue, it’s better to remove deductions than increase marginal tax rates.”

Such a move would be fiercely opposed by the real estate industry. The industry has played a crucial role in defending the tax break, even as other countries with high homeownership have phased it out.

Housing market players who oppose any whittling down of the mortgage deduction still have time to press their case. If President Obama and Congress manage to reach an agreement to avoid the looming tax raises and spending cuts, their deal will be broad in nature. Then, over the following months, Congress will hash out details, like any caps on deductions.

“Until Congress introduces specific legislation, there’s nothing to say about any proposed changes to the mortgage interest deduction,” Gary Thomas, president of the National Association of Realtors, said in an e-mailed statement. “However, it has always been the N.A.R.’s position that the mortgage interest deduction is vital to the stability of the American housing market and economy, and we will remain vigilant in opposing any future plan that modifies or excludes the deductibility of mortgage interest.”

One of the reasons the mortgage tax break is so vulnerable is that both Democrats and Republicans have recently favored capping deductions, including both President Obama and the recent Republican presidential nominee, Mitt Romney.

What is more, deductions could be used to grease a compromise in the budget negotiations. High earners would be hit most by deduction limits, something that might make Republicans recoil. But the party may tolerate such a policy in return for a deal that limits how much actual tax rates go up for high-income households.

Tax numbers suggest it may not be hard to structure deduction limits in a way that leaves most middle-income households untouched.

With the mortgage interest deduction, households realized tax savings of $83 billion in 2010, according to figures from the Reason Foundation. Nearly $65 billion, or 78 percent of those savings, went to households earning $100,000 or more.

There are a range of ways to increase tax revenue by aiming at higher earners, some less comprehensive than others. For instance, the interest deduction relating to second homes could be ended. Also, the cap on mortgage debt eligible for the interest rate deduction — currently $1 million — could be reduced.

There are broader approaches, too. In its proposed budget, the Obama administration plans to focus on top earners. The administration suggests capping deductions at 28 percent for high-income households, those earning more than $250,000.

Under the current rules, a high-earning household deducting $20,000 in interest payments would probably apply a 35 percent rate to that amount and receive $7,000 in tax savings. The Obama budget aims to limit that tax saving by capping that rate at 28 percent. If that rate were applied to $20,000 of interest payments, the saving would fall to $5,800.

The United States would capture the difference. Over the next 10 years, that 28 percent cap could increase tax revenue by $584 billion, according to the Treasury Department.

Separately, the Obama administration also wants to limit high earners’ deductions by letting certain Bush-era exemptions expire. Altogether, the Treasury Department thinks it could raise $749 billion over 10 years by limiting deductions for higher earners. That’s substantially more than the $684 billion it thinks it could raise from increasing their tax rates.

Still, there are situations where certain middle-income earners do get hit by deduction limits.

Consider a policy that uses a dollar limit, and caps all deductions at $35,000. That amount would be plenty to cover most middle-income households’ mortgage interest, state and local taxes and charitable giving.

But people earnings more than $100,000 may start to reach the limit, according to Sidney B. Rosenberg, associate professor emeritus at the University of North Florida. He assumes a household earns $110,000 and has a $300,000 mortgage on which it pays $17,500 a year. It also pays property taxes and state taxes at estimated nationally average rates. Such a family would have nearly $35,000 of deductible expenses, Dr. Rosenberg calculates.

One argument against curtailing the mortgage deduction is that it could reduce demand for housing, depressing home prices when the housing market is still somewhat weak. The National Association of Realtors believes a removal of the deduction could reduce property values by 15 percent, according to a presentation last year from its chief economist, Lawrence Yun.

Other analysts say they believe the housing industry overstates the potential impact. With several forms of government subsidy also supporting housing, it’s hard to single out the effect of the mortgage deduction. At the most, the Reason Foundation estimates, the deduction may bolster house prices by 3 percent.

Since any deduction cap is likely to aim at higher earners, expensive houses would be most affected. But big-ticket homes appear much more resilient to shocks than lower-cost dwellings.

CoreLogic, a housing data company, tracks data that effectively divides the market into higher- and lower-cost houses, grouping them based on the size of the mortgages. The prices of the higher-cost houses are up 5.9 percent since the start of 2005, before the housing crash. In contrast, the houses at the lower end have fallen 13.5 percent in price since the beginning of 2005.

Given the apparent sturdiness of the higher end of the housing market, politicians may decide there are few risks in effectively capping mortgage deductions for high earners. Limiting tax breaks in a way that could reduce mortgage relief would be a change for Washington, which has done so much to support housing.

Nick Kasprak, an analyst at the Tax Foundation, said that up until recently he didn’t expect to see a cap on deductions. “But now,” he said, “it seems both parties are open to pursuing this strategy.”

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Bangladesh Fire Kills More Than 100 and Injures Many

MUMBAI — More than 100 people died Saturday and Sunday in a fire at a garment factory outside Dhaka, Bangladesh, in one of the worst industrial tragedies in that country.

It took firefighters all night to put out the blaze at the factory, Tazreen Fashions, after it started about 7 p.m. on Saturday, a retired fire official said by telephone from Dhaka, the capital. At least 111 people were killed, and scores of workers were taken to hospitals for treatment of burns and smoke inhalation.

“The main difficulty was to put out the fire; the sufficient approach road was not there,” said the retired official, Salim Nawaj Bhuiyan, who now runs a fire safety company in Dhaka. “The fire service had to take great trouble to approach the factory.”

Bangladesh’s garment industry, the second-largest exporter of clothing after China, has a notoriously poor fire safety record. Since 2006, more than 500 Bangladeshi workers have died in factory fires, according to Clean Clothes Campaign, an antisweatshop advocacy group in Amsterdam. Experts say many of the fires could have been easily avoided if the factories had taken the right precautions. Many factories are in cramped neighborhoods and have too few fire escapes, and they widely flout safety measures. The industry employs more than three million workers in Bangladesh, most of them women.

Activists say that global clothing brands like Tommy Hilfiger and the Gap and those sold by Walmart need to take responsibility for the working conditions in Bangladeshi factories that produce their clothes.

“These brands have known for years that many of the factories they choose to work with are death traps,” Ineke Zeldenrust, the international coordinator for the Clean Clothes Campaign, said in a statement. “Their failure to take action amounts to criminal negligence.”

The fire at the Tazreen factory in Savar, northwest of Dhaka, started in a warehouse on the ground floor that was used to store yarn, and quickly spread to the upper floors. The building was nine stories high, with the top three floors under construction, according to an garment industry official at the scene who asked not to be named because he was not authorized to speak to the news media. Though most workers had left for the day when the fire started, the industry official said as many as 600 workers were still inside working overtime.

The factory, which opened in May 2010, employed about 1,500 workers and had sales of $35 million a year, according to a document on the company’s Web site. It made T-shirts, polo shirts and fleece jackets.

Most of the workers who died were on the first and second floors, fire officials said, and were killed because there were not enough exits. None of them opened to the outside.

“The factory had three staircases, and all of them were down through the ground floor,” said Maj. Mohammad Mahbub, the operations director for the Fire Department, according to The Associated Press. “So the workers could not come out when the fire engulfed the building.”

In a telephone interview later on Sunday, Major Mahbub said the fire could have been caused by an electrical fault or by a spark from a cigarette.

In a brief phone call, Delowar Hossain, the managing director of the Tuba Group, the parent company of Tarzeen Fashions, said he was too busy to comment. “Pray for me,” he said and then hung up.

Television news reports showed badly burned bodies lined up on the floor in what appeared to be a government building. The injured were being treated in hallways of local hospitals, according to the reports.

The industry official said that many of the bodies were burned beyond recognition and that it would take some time to identify them.

One survivor, Mohammad Raju, 22, who worked on the fifth floor, said he escaped by climbing out of a third-floor window onto the bamboo scaffolding that was being used by construction workers. He said he lost his mother, who also worked on the fifth floor, when they were making their way down.

“It was crowded on the stairs as all the workers were trying to come out from the factory,” Mr. Raju said. “There was no power supply; it was dark, and I lost my mother in dark. I tried to search for her for 10 to 15 minutes but did not find her.”

A document posted on Tarzeen Fashions’ Web site indicated that an “ethical sourcing” official for Walmart had flagged “violations and/or conditions which were deemed to be high risk” at the factory in May 2011, though it did not specify the nature of the infractions. The notice said that the factory had been given an “orange” grade and that any factories given three such assessments in two years from their last audit would not receive any Walmart orders for a year.

It was unclear whether Walmart had suspended the company or was still buying clothes from it. The Web sites of Tuba Group lists the retailer and others like Carrefour, a French retail chain, as customers. A spokesman for Walmart, Kevin Gardner, said the company was “so far unable to confirm that Tazreen is supplier to Walmart nor if the document referenced in the article is in fact from Walmart.”

Bangladesh exports about $18 billion worth of garments a year. Employees in the country’s factories are among the lowest-paid in the world, with entry-level workers making a government-mandated minimum wage of about $37 a month.

Tensions have been running high between workers, who have been demanding an increase in minimum wages, and the factory owners and government. A union organizer, Aminul Islam, who campaigned for better working conditions and higher wages, was found tortured and killed outside Dhaka this year.

Fire safety remains weak across much of South Asia. In September, nearly 300 workers were killed in a fire at a textile factory in Karachi, Pakistan, just weeks before it passed an inspection that covered several issues, including health and safety.

Julfikar Ali Manik contributed reporting from Dhaka, Bangladesh, and Stephanie Clifford from New York.

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