The New Old Age Blog: Grief Over New Depression Diagnosis

When the American Psychiatric Association unveils a proposed new version of its Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatric diagnoses, it expects controversy. Illnesses get added or deleted, acquire new definitions or lists of symptoms. Everyone from advocacy groups to insurance companies to litigators — all have an interest in what’s defined as mental illness — pays close attention. Invariably, complaints ensue.

“We asked for commentary,” said David Kupfer, the University of Pittsburgh psychiatrist who has spent six years as chairman of the task force that is updating the handbook. He sounded unruffled. “We asked for it and we got it. This was not going to be done in a dark room somewhere.”

But the D.S.M. 5, to be published in May, has generated an unusual amount of heat. Two changes, in particular, could have considerable impact on older people and their families.

First, the new volume revises some of the criteria for major depressive disorder. The D.S.M. IV (among other changes, the new manual swaps Roman numerals for Arabic ones) set out a list of symptoms that over a two-week period would trigger a diagnosis of major depression: either feelings of sadness or emptiness, or a loss of interest or pleasure in most daily activities, plus sleep disturbances, weight loss, fatigue, distraction or other problems, to the extent that they impair someone’s functioning.

Traditionally, depression has been underdiagnosed in older adults. When people’s health suffers and they lose friends and loved ones, the sentiment went, why wouldn’t they be depressed? A few decades back, Dr. Kupfer said, “what was striking to me was the lack of anyone getting a depression diagnosis, because that was ‘normal aging.’” We don’t find depression in old age normal any longer.

But critics of the D.S.M. 5 now argue that depression may become overdiagnosed, because this version removes the so-called “bereavement exclusion.” That was a paragraph that cautioned against diagnosing depression in someone for at least two months after loss of a loved one, unless that patient had severe symptoms like suicidal thoughts.

Without that exception, you could be diagnosed with this disorder if you are feeling empty, listless or distracted, a month after your parent or spouse dies.

“D.S.M. 5 is medicalizing the expected and probably necessary process of mourning that people go through,” said Allen Frances, a professor emeritus at Duke who chaired the D.S.M. IV task force and has denounced several of the changes in the new edition. “Most people get better with time and natural healing and resilience.”

If they are diagnosed with major depression before that can happen, he fears, they will be given antidepressants they may not need. “It gives the drug companies the right to peddle pills for grief,” he said.

An advisory committee to the Association for Death Education and Counseling also argued that bereaved people “will receive antidepressant medication because it is cheaper and ‘easier’ to medicate than to be involved therapeutically,” and noted that antidepressants, like all medications, have side effects.

“I can’t help but see this as a broad overreach by the APA,” Eric Widera, a geriatrician at the University of California, San Francisco, wrote on the GeriPal blog. “Grief is not a disorder and should be considered normal even if it is accompanied by some of the same symptoms seen in depression.”

But Dr. Kupfer said the panel worried that with the exclusion, too many cases of depression could be overlooked and go untreated. “If these things go on and get worse over time and begin to impair someone’s day to day function, we don’t want to use the excuse, ‘It’s bereavement — they’ll get over it,’” he said.

The new entry for major depressive disorder will include a note — the wording isn’t final — pointing out that while grief may be “understandable or appropriate” after a loss, professionals should also consider the possibility of a major depressive episode. Making that distinction, Dr. Kupfer said, will require “good solid clinical judgment.”

Initial field trials testing the reliability of D.S.M. 5 diagnoses, recently published in The American Journal of Psychiatry, don’t bolster confidence, however. An editorial remarked that “the end results are mixed, with both positive and disappointing findings.” Major depressive disorder, for instance, showed “questionable reliability.”

In an upcoming post, I’ll talk more about how patients might respond to the D.S.M. 5, and to a new diagnosis that might also affect a lot of older people — mild neurocognitive disorder.

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

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This post has been revised to reflect the following correction:

Correction: January 24, 2013

An earlier version of this post misspelled the surname of a professor emeritus at Duke who chaired the D.S.M. IV task force. He is Allen Frances, not Francis.

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Apple shares tumble after relatively unimpressive earnings report

Apple Inc. may still make products customers love, but its latest earnings report appears to have broken investors' hearts.

For the third quarter in a row, Apple reported revenue and profit that were impressive by normal standards, but short of what analysts had expected. Investors reacted harshly, driving Apple's stock price down more than 10% in after-hours trading Wednesday.

If that trend holds when trading opens Thursday, Apple will have lost almost $50 billion in market value in the blink of an eye, and its stock will have given up almost all the extraordinary gains it had made in the last year. Investors' and fund managers' belief in one of the world's most widely held stocks will be severely tested in the coming days.

More fundamentally, despite upbeat talk by Apple Chief Executive Tim Cook, the performance is unlikely to quell growing worries that Apple's remarkable run of dominance might be over.

"Overall, compared to other companies, it's impressive. But for Apple's standards, it's not great," said Patrick Moorhead of Moor Insights & Strategy. "I do think this somewhat fuels the perception that Apple is slowing down a bit.... And it's driven by the fact that some of its competitors are catching up, and in some markets have already caught up."

Apple executives did their best during an hourlong conference call with analysts to project optimism and excitement about both the last quarter and the months ahead. They noted that the company had trouble meeting demand for both iPads and Macs, and could have sold many more had they been able to build enough.

They also pointed to a growing business in China and the expansion of iTunes, which is now available in 119 countries.

"Apple is in one of the most prolific periods of innovation in its history," Cook said. "We continue to believe our fundamentals, our remarkable people, our clear and focused strategy will serve us well in the coming months and years ahead."

Cook praised the record numbers posted by Apple. For the three months that ended in December, Apple said revenue increased 18% to a record $54.5 billion. Profit also set an all-time high but was up only slightly from the year-earlier quarter, rising to $13.08 billion, or $13.81 a share, from $13.06 billion, or $13.87.

Apple said it sold a record 47.8 million iPhones last quarter, up from 37 million iPhones in the same quarter of 2011. Despite that massive figure, some analysts had hoped to see stronger demand with sales exceeding 50 million.

"Meeting expectations is not enough for Apple," said Colin Gillis of BGC Financial. "So that's a little bit of a disappointment…. International sales were a little weaker than people expected. So we'll see how that shakes out."

Last quarter saw the introduction of the iPad mini, a 7.9-inch version of Apple's popular tablet computer. The Cupertino, Calif., company said it sold a total of 22.9 million iPads in the quarter, also a record, up from 15.4 million a year earlier. The company didn't break out iPad mini numbers from its total tablet sales, but Chief Financial Officer Peter Oppenheimer told analysts that the smaller version has been a hit and that the company experienced significant backlog getting the product to store shelves. The 22% lower average selling price for Apple's tablets suggests the mini has performed well but probably cannibalized some sales of its 9.7-inch version.

Historic comparisons were challenging this year because the most recent quarter had only 13 weeks, compared with 14 weeks for the same quarter of 2011.

Like many retailers and consumer electronics companies, the quarter from October to December is typically Apple's largest because of the holiday shopping season. Last year, Apple managed to stun investors by beating its own revenue estimates by more than 25% and earnings forecast by nearly 50%. That sent the stock soaring.

But even as Apple extended its lead as the world's most valuable company, and set a record in August for most valuable company ever when not adjusted for inflation, doubts began to creep into the minds of analysts and investors.

Shares have plummeted 27% in the last four months. On Wednesday, shares rose $9.24, or 1.8%, to $514.01 during regular trading.

Apple reported strong earnings in both the third and fourth quarters last year, but the numbers missed analysts' consensus estimates. Gradually, analysts began lowering their forecasts for Apple's earnings for the current fiscal year. At the same time,

Apple experienced some uncharacteristic gaffes. The new Apple Maps app that replaced Google Maps on iOS 6 devices had reliability problems, prompting a rare apology by Apple. And the iPhone 5 that went on sale in September faced long shipping delays as Apple suppliers struggled to adapt to the new, longer screen size.

The dismissal of iOS chief Scott Forstall, a favorite of the late Apple co-founder Steve Jobs, raised eyebrows. But so did a new strategy for launching products: Whereas Apple updates to products used to be few and far between, the company has lately begun increasing the number of products as well as the introduction of new versions.

The first quarter saw one of the busiest product launch cycles in the company's history. The quarter was the first full quarter of sales for the iPhone 5, a new iPod Touch and nano, the fourth iPad, a new 13-inch Retina MacBook Pro, and, of course, the first iPad mini.

Observers have pointed to this accelerated pace as an indication that Apple is facing more competitive pressure from rivals such as Samsung Electronics Co., which is now the world's biggest seller of smartphones, with its Galaxy series of phones. The concern is that the faster upgrade cycle plus the smaller iPad mini will cut into Apple's historically high profit margins.

Such fears over lower profits have also been stoked by the debate over whether Apple plans to release a cheaper iPhone aimed at capturing market share in emerging economies and the concern that Apple has not been able to strike a deal with China's largest carrier.

Now that the first-quarter numbers have been released, analysts will be busy recalibrating their projections over the next couple of days. But the focus is also likely to shift to renewed speculation about new products that investors are hoping will drive another big run for the stock.

chris.obrien@latimes.com

andrea.chang@latimes.com

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House GOP seeks steep cuts while raising debt ceiling

— Stepping up their austerity campaign, House Republicans plan to demand far deeper spending cuts from President Obama to balance the federal budget in just 10 years, an extraordinary goal that would hit Medicare and other safety-net programs.

House Speaker John A. Boehner (R-Ohio), confronted with a more conservative Republican majority, agreed to the dramatic initiative to coax reluctant rank-and-file lawmakers Wednesday to approve a temporary suspension of the $16.4-trillion debt limit without any cuts in spending.

The new proposal to balance the budget in a decade would zero out the federal deficit almost twice as fast as previous Republican efforts.

"It's time for us to get serious about how over the next 10 years we balance this budget and put America on a sustainable fiscal path," the speaker said after the debt ceiling measure passed the House, 285 to 144. It now goes to the Senate, which is also expected to approve it.

The House vote puts the White House and Congress on another collision course in the budget battles that are expected to consume the first months of Obama's second term.

Republicans, who agreed to tax increases on the wealthy in the year-end budget deal, have insisted that the next round of deficit reduction must come from the spending side of the ledger.

But because Republicans want to protect the Pentagon, their approach would require steep reductions in domestic programs — particularly education, infrastructure investment and the safety net for low- and moderate-income Americans.

House Republicans will write their new budget in the coming weeks, but similar blueprints for eliminating the deficit in 10 years have pointed to austere measures: turning Medicare into a voucher-like program and raising the age at which seniors become eligible, cutting food stamps and school lunch subsidies, and holding other domestic accounts flat.

Republicans believe the public will be on their side, even though they lost the presidential election with the architect of the last House budget on the ticket. Rep. Paul D. Ryan of Wisconsin, the wonkish Budget Committee chairman, again will take the lead in crafting the new budget.

Ryan said he did not see the electoral loss as a rejection of the party's principles. "I think we need to do a better job of applying our principles to the problems of today, to show solutions to the country's biggest problems and how they relate in people's everyday lives," he told reporters Wednesday at a breakfast hosted by the Wall Street Journal.

The nation has been running record yearly deficits, topping $1 trillion, almost since Obama took office. That largely stems from plummeting tax revenue during the recession and increased spending on the recovery effort and on healthcare costs for an aging population.

The debt load doubled during President George W. Bush's two terms with the wars overseas, and continues to rise toward levels that many economists say would destabilize interest rates and the economy. Closing the budget gap would require a $5-trillion adjustment over the decade.

Some economists, such as Paul N. Van de Water, a senior fellow at the Center on Budget and Policy Priorities, say the political effort that would require could be better focused elsewhere.

"Trying to balance the budget is a needlessly ambitious goal," he said. "Certainly a reasonable interim goal would be to cut deficits enough to make sure the debt doesn't keep rising as a share of the economy."

The Senate, which is controlled by Democrats, plans to contrast the Ryan approach with its own budget, which is expected to raise revenue by closing tax breaks for the wealthy and loopholes that benefit specific industries, including oil and gas.

"The American people went to the polls and strongly endorsed the Democrats' balanced approach that puts jobs and the middle class first, calls on the wealthy to pay their fair share," said Sen. Patty Murray (D-Wash.), the incoming chairman of the Senate Budget Committee.

Even before April 15, when the House and Senate face a deadline to pass budgets, a series of built-in deadlines will force both sides to negotiate. On March 1, the federal budget faces $1.2 trillion in automatic spending cuts that both sides want to alter. Then on March 27, Congress will need to approve money for routine government operations, or risk a shutdown.

After the short-term debt ceiling measure expires on May 18, the ceiling would need to be raised again, although the Treasury could take measures to extend borrowing into July.

Conservatives continue to object to raising the debt ceiling, as was evident Wednesday when 33 opposed the measure. That forced Boehner to find Democratic votes for passage.

Boehner had sweetened the legislation to attract support by attaching a provision that would temporarily withhold the pay of senators or representatives if their chamber failed to produce an annual budget by the deadline. The tactic drew Democratic and Republican votes.

But some Democrats complained Wednesday that Republicans were simply setting up another "fiscal cliff." Rep. Sander M. Levin (D-Mich.) said, "House Republicans continue to play with economic fire."

lisa.mascaro@latimes.com

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Voice actor for Charlie Brown arrested in Calif.

SAN DIEGO (AP) — The man who was the voice of Charlie Brown in several "Peanuts" television shows was charged Wednesday with stalking and threatening his former girlfriend and a plastic surgeon who gave her a breast enhancement he apparently didn't like.

Peter Robbins pleaded not guilty Wednesday in San Diego Superior Court to two counts of stalking and 10 counts of making criminal threats.

Prosecutors said the 56-year-old voice actor best known for his portrayal of Charlie Brown on the TV special "A Charlie Brown Christmas" repeatedly threatened his former girlfriend, calling her as many as 37 times in a 24-hour period on her cellphone and telling her he would kill her and her son if she did not give back his dog and car.

Prosecutors said he also threatened the plastic surgeon in the coastal city of Carlsbad, calling her office so many times she moved to a hotel temporarily out of fear for her life and hired an armed guard outside her clinic. Authorities said Robbins paid for the breast enhancement and was demanding his money back after they broke up, according to the criminal complaint.

On Dec. 31, Robbins allegedly confronted his former girlfriend in a hotel room, beating his dog and telling her he would not stop hurting the animal and would kill her if she did not get a refund for the surgery, Deputy District Attorney Elizabeth McClutchey told the judge in arguing that bail be increased to $550,000. McClutchey said he then grabbed his ex-girlfriend by the neck and shoved her against the door before fleeing.

Prosecutors also told the judge that Robbins had recently purchased a gun and had been practicing at a shooting range. San Diego Superior Court Judge David M. Szumowski agreed to up the bail from $50,000 to $550,000.

Robbins was arrested Sunday at the San Ysidro Port of Entry after authorities doing a background check upon his return from Mexico spotted a warrant from the San Diego County Sheriff's Department.

Robbins was best known for his performance as the voice of Charlie Brown on "A Charlie Brown Christmas" and "It's the Great Pumpkin, Charlie Brown."

Defense Attorney Marc S. Kohnen told the judge the bail was set too high for a man with no prior criminal record, who has lived in San Diego County for 30 years and whose work is watched by so many children to this day. He called him a "distraught man" and said "this is not a stalking case" but declined to comment on what led to his arrest.

"Mr. Robbins is an eccentric individual," Kohnen told reporters after the arraignment. "He's not a threat to society."

If convicted, he would face a maximum sentence of up to nine years in prison, prosecutors said.

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Well: Long Term Effects on Life Expectancy From Smoking

It is often said that smoking takes years off your life, and now a new study shows just how many: Longtime smokers can expect to lose about 10 years of life expectancy.

But amid those grim findings was some good news for former smokers. Those who quit before they turn 35 can gain most if not all of that decade back, and even those who wait until middle age to kick the habit can add about five years back to their life expectancies.

“There’s the old saw that everyone knows smoking is bad for you,” said Dr. Tim McAfee of the Centers for Disease Control and Prevention. “But this paints a much more dramatic picture of the horror of smoking. These are real people that are getting 10 years of life expectancy hacked off — and that’s just on average.”

The findings were part of research, published on Wednesday in The New England Journal of Medicine, that looked at government data on more than 200,000 Americans who were followed starting in 1997. Similar studies that were done in the 1980s and the decades prior had allowed scientists to predict the impact of smoking on mortality. But since then many population trends have changed, and it was unclear whether smokers today fared differently from smokers decades ago.

Since the 1960s, the prevalence of smoking over all has declined, falling from about 40 percent to 20 percent. Today more than half of people that ever smoked have quit, allowing researchers to compare the effects of stopping at various ages.

Modern cigarettes contain less tar and medical advances have cut the rates of death from vascular disease drastically. But have smokers benefited from these advances?

Women in the 1960s, ’70s and ’80s had lower rates of mortality from smoking than men. But it was largely unknown whether this was a biological difference or merely a matter of different habits: earlier generations of women smoked fewer cigarettes and tended to take up smoking at a later age than men.

Now that smoking habits among women today are similar to those of men, would mortality rates be the same as well?

“There was a big gap in our knowledge,” said Dr. McAfee, an author of the study and the director of the C.D.C.’s Office on Smoking and Public Health.

The new research showed that in fact women are no more protected from the consequences of smoking than men. The female smokers in the study represented the first generation of American women that generally began smoking early in life and continued the habit for decades, and the impact on life span was clear. The risk of death from smoking for these women was 50 percent higher than the risk reported for women in similar studies carried out in the 1980s.

“This sort of puts the nail in the coffin around the idea that women might somehow be different or that they suffer fewer effects of smoking,” Dr. McAfee said.

It also showed that differences between smokers and the population in general are becoming more and more stark. Over the last 20 years, advances in medicine and public health have improved life expectancy for the general public, but smokers have not benefited in the same way.

“If anything, this is accentuating the difference between being a smoker and a nonsmoker,” Dr. McAfee said.

The researchers had information about the participants’ smoking histories and other details about their health and backgrounds, including diet, alcohol consumption, education levels and weight and body fat. Using records from the National Death Index, they calculated their mortality rates over time.

People who had smoked fewer than 100 cigarettes in their lifetimes were not classified as smokers. Those who had smoked at least 100 cigarettes but had not had one within five years of the time the data was collected were classified as former smokers.

Not surprisingly, the study showed that the earlier a person quit smoking, the greater the impact. People who quit between 25 and 34 years of age gained about 10 years of life compared to those who continued to smoke. But there were benefits at many ages. People who quit between 35 and 44 gained about nine years, and those who stopped between 45 and 59 gained about four to six years of life expectancy.

From a public health perspective, those numbers are striking, particularly when juxtaposed with preventive measures like blood pressure screenings, colorectal screenings and mammography, the effects of which on life expectancy are more often viewed in terms of days or months, Dr. McAfee said.

“These things are very important, but the size of the benefit pales in comparison to what you can get from stopping smoking,” he said. “The notion that you could add 10 years to your life by something as straightforward as quitting smoking is just mind boggling.”

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Number of homes entering foreclosure drops 22.1% to six-year low

California's foreclosure crisis eased considerably during the final quarter of last year, with the number of homes entering foreclosure dropping to a six-year low.

The steep decline, accompanied by a similar drop in home repossessions, clears the path for a quickened pace of recovery this year. Fewer foreclosures on the market should lead to higher home prices and a healthier real estate market.

"Ultimately, fewer foreclosures means an even tighter market, which means a more rapid recovery," said Christopher Thornberg, a principal at Beacon Economics. "I see very little to forestall the real estate market this year."

The real estate research firm DataQuick reported a 22.1% decline in default notices during the final three months of 2012 compared with the previous quarter — and a 37.9% drop from a year earlier. A total of 38,212 default notices were logged on California houses and condominiums last quarter, the lowest number since the final quarter of 2006. A default notice is the first formal step in the state's foreclosure process.

Since the number of new foreclosure cases peaked in early 2009, experts and analysts have feared a second wave of home loan defaults flooding the market. Three years later, that appears unlikely as banks turn to foreclosure alternatives and home prices rise.

"We are past the peak of this," said Kenneth Rosen, chairman of the Fisher Center for Real Estate and Urban Economics at UC Berkeley's Haas School of Business.

A steadily improving economy has helped ease homeowner woes. And the vast number of underwater borrowers — those owing more on their homes than they're worth — have continued to pay their mortgages instead of walking away. Rising home prices should help more underwater homeowners come up for air, allowing them to regain equity and sell their homes if they run into financial trouble.

"Home values increased through most of 2012, and the rate of increase picked up toward the end of the year," DataQuick President John Walsh said in a news release. "That means fewer and fewer homeowners are underwater."

California's median home price rose 22.4% last quarter to $300,000.

California has also been able to work through its foreclosure problem faster than other states, in part because foreclosures take place largely outside the courtroom, said Celia Chen, a housing economist with Moody's Economy.com. That means California has not been bogged down with the same level of paperwork issues and delays that states such as Florida or New York have experienced.

California has also benefited from economic growth from Asian trade and from the technology industry centered around Silicon Valley. Indeed, the technology-rich Bay Area's declines in default notices outpaced both the statewide drops and those in every other region.

Those foreclosed homes that are hitting the market are being snapped up by investors to either rent or flip. Investors bought 42% of all homes sold at foreclosure auctions statewide last quarter, according to DataQuick.

Big hedge funds have become so interested in cheaply priced homes that flippers are now increasingly searching for homes in the $400,000 to $600,000 range throughout Los Angeles County, said Robert Fragoso, executive vice president for Anchor Loans, which makes short-term loans to investors. The new interest among renovators in pricier homes should also push up prices. Already, some homes are selling for more than the asking price, Fragoso said.

"I am seeing the inventory levels right now at very, very, very low rates, especially when you are talking about the product that has already been remodeled," he said. "We are getting multiple offers on almost everything within days of it hitting the market."

Banks have been increasingly averse to foreclosure because state and federal regulators increased scrutiny on the process, which led to huge settlements as well as new laws. Major lenders have now stepped up short sales and other kinds of loan modifications to deal with troubled borrowers.

Although the foreclosure crisis has abated, the number of people losing their homes remains at a very high level compared with historical averages, said Paul Leonard, California director for the Center for Responsible Lending. Those entering foreclosure are most likely people suffering from California's still tough economy or those with the most limited resources. Aid programs and reforms by federal and state authorities are still needed, he said.

"One has to be very cautious," Leonard said, "even as we have seen substantial declines in the overall levels of default and foreclosure."

alejandro.lazo@latimes.com

andrew.khouri@latimes.com

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Mali conflict shakes country's faith in its leaders

BAMAKO, Mali — The commander of Mali's army is so confident of a swift French and Malian military victory against Al Qaeda-linked militias in his country's north that he declared that the war would be over in a month.

Taxi drivers and shopkeepers listened to Ibrahim Dahirou Dembele on crackly radios across this dusty capital Tuesday after the French military had driven militants out of the key central towns of Diabaly and Douentza on Monday.

But on one shady street corner in Bamako, university lecturer Yacouba Diallo, 30, who'd come for his customary afternoon glass of foamy bittersweet tea, wasn't sure that the Islamists could be so easily eliminated. He fears that once French troops depart, the threat will reemerge.

"The Malian military has been tested in this war and found wanting. Everyone knows that if there was no French intervention, the Malian army couldn't have resisted the jihadists," he said, downing the small glass of strong tea in a gulp.

"When I was young, I thought we had one of the strongest armies in the region, but with this war, I saw otherwise. I was shocked the army couldn't stop the Islamists' advance."

Like many Malians, Diallo is experiencing a crisis of confidence in the Malian state and its army. For him, the rapid retreat of the militants in the last few days isn't quite enough to erase the recent terror at the prospect of them reaching the capital and taking power, a fear that took shape as the rebels advanced southward this month, swiftly seizing territory.

The fear intensified after the Islamists overran the town of Konna on Jan. 10, threatening Mopti, about 140 miles from Bamako, and nearby Sevare, which is important for its major airport.

It was terrifying at the time, but sporting goods store owner Mamadou Traore, 41, who carries the latest smartphone in his pocket, can laugh about it now.

"Everyone was just expecting to see them here in Bamako. Everyone would have had to give up smoking," he said, chuckling huskily. "And everyone would have cut their pants short because that is what the Islamists say." (Some Muslim fundamentalists believe that a man's garment should not be worn below the ankle.)

Three militant groups — Ansar Dine; the Movement for Unity and Jihad in West Africa, known by its French initials, MUJOA; and Al Qaeda in the Islamic Maghreb, or AQIM — remain in the northern towns of Timbuktu, Gao and Kidal, according to Alexis Kalambry, editor of Les Echos newspaper in Bamako, whose journalists are filing reports from the north.

After the fall of Libyan leader Moammar Kadafi in 2011, militias swept across Mali's porous border with what activists say were truckloads of looted weapons, eventually launching a rebellion.

They took advantage of the chaos and paralysis that followed a military coup in Mali last March, seizing control of the country's north. Nomadic Tuareg fighters, under the banner of the National Movement for the Liberation of Azawad, launched a push to create an independent Tuareg homeland, but they were soon driven out by Ansar Dine and other extremists, who imposed a strict interpretation of Islamic law that is at odds with local custom.

Under that interpretation, they have been stoning people, amputating limbs and placing severe restrictions on women's clothing and movement.

France has deployed 2,150 troops out of a planned 2,500 in an effort — highly popular in Mali — aimed at driving out the Islamists, restoring the country's territorial integrity and stabilizing it politically. French flags are on sale in the capital along with the flag of Mali, which is being raised to celebrate the nation's participation in Africa's international soccer tournament, the Africa Cup of Nations, underway in South Africa.

"I really appreciate the bombing by the French forces," said Traore, the sporting goods store owner, surrounded by shelves loaded with dozens of uninflated soccer balls. "Anything that happens to those jihadists is a good thing. They fight in the name of Islam but they are not good Muslims. They abused women; they amputated people's limbs. How can you call them Muslims?"

Ask him about reports of civilian casualties in the French bombings and he swiftly brushes it aside.

"It's impossible to protect all civilians when bombing is going on," he said.

Traore's business has not been affected by the war, but Mali's economy was hit by the collapse of the tourist industry after extremists last year captured the main tourist sites in the north, including ancient mausoleums in Timbuktu, and after several kidnappings and killings of foreigners in the Sahel region in recent years.

"With the terrorist advance, no tourists are coming, so the economy is depressed," said Diallo, the university lecturer. "We don't know how long will it be before tourists come back to the northern cities."

Many Malians hope the French will stay at least a year, doubting as they doubt that Mali's army can protect them from the Islamists, even with a planned 3,300-strong force of regional African troops, about a third of whom have arrived in Mali.

"When France leaves, the question is whether it is possible for Malian troops to ensure security. That's the big question," Diallo said.

"The few remaining rebels might not be able to face French and Malian troops in battle, but what's going to be dangerous is they are here now and we don't know where they are, and they can launch bombings and attacks on the population at any time," he said. "They can still be dangerous."

robyn.dixon@latimes.com

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Shakira gives birth to baby boy

LOS ANGELES (AP) — Shakira is a mama.

A spokeswoman for the 35-year-old Colombian singer says Shakira Mebarak and 25-year-old soccer star Gerard Pique of FC Barcelona welcomed son Milan Pique Mebarak on Tuesday at 9:36 p.m. in Barcelona, Spain.

A statement posted on the pop star's site in English, Spanish and Catalan says that "just like his father, baby Milan became a member of FC Barcelona at birth." The statement also says Milan weighed approximately 6 pounds, 6 ounces, and that "both mother and child are in excellent health."

Shakira asked fans earlier Tuesday on Twitter "to accompany me in your prayers on this very important day of my life."

Milan is the couple's first child.

___

Online:

http://shakira.com/

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Medicaid Patients Could Face Higher Fees Under a Proposed Federal Policy

WASHINGTON — Millions of low-income people could be required to pay more for health care under a proposed federal policy that would give states more freedom to impose co-payments and other charges on Medicaid patients.

Hoping to persuade states to expand Medicaid, the Obama administration said state Medicaid officials could charge higher co-payments and premiums for doctors’ services, prescription drugs and certain types of hospital care, including the “nonemergency use” of emergency rooms. State officials have long asked for more leeway to impose such charges.

The 2010 health care law extended Medicaid to many childless adults and others who were previously ineligible. The Supreme Court said the expansion of Medicaid was an option for states, not a requirement as Congress had intended. The administration has been trying to persuade states to take the option, emphasizing that they can reconfigure Medicaid to hold down their costs and “promote the most effective use of services.”

In the proposed rule published Tuesday in the Federal Register, the administration said it was simplifying a complex, confusing array of standards that limit states’ ability to charge Medicaid beneficiaries. Under the proposal, a family of three with annual income of $30,000 could be required to pay $1,500 in premiums and co-payments.

As if to emphasize the latitude given to states, the administration used this heading for part of the new rule: “Higher Cost Sharing Permitted for Individuals With Incomes Above 100 Percent of the Federal Poverty Level” (that is, $19,090 for a family of three).

Barbara K. Tomar, director of federal affairs at the American College of Emergency Physicians, said the administration had not adequately defined the “nonemergency services” for which low-income people could be required to pay. In many cases, she said, patients legitimately believe they need emergency care, but the final diagnosis does not bear that out.

“This is just a way to reduce payments to physicians and hospitals” from the government, Ms. Tomar said.

With patients paying more, the federal government and states would pay less than they otherwise would. Medicaid covers 60 million people, and at least 11 million more are expected to qualify under the 2010 law. The federal government pays more than half of Medicaid costs and will pay a much larger share for those who become eligible under the law.

In the proposed rule, the administration said it had discovered several potential problems in its efforts to carry out the law.

First, it said, it has not found a reliable, comprehensive and up-to-date source of information about whether people have employer-sponsored health insurance. The government needs such information to decide whether low- and middle-income people can obtain federal subsidies for private insurance.

The subsidies can be used to buy coverage in competitive marketplaces known as insurance exchanges. Under the law, people can start enrolling in October for coverage that starts in January 2014, when most Americans will be required to have health insurance. People who have access to affordable coverage from employers will generally be ineligible for subsidies.

In applying for subsidies, people must report any employer-sponsored insurance they have. But the administration said it could be difficult to verify this information because the main sources of data reflect only “whether an individual is employed and with which employer, and not whether the employer provides health insurance.”

Since passage of the health care law, the administration has often said that people seeking insurance would use a single streamlined application for Medicaid and the subsidies for private coverage. Moreover, the state Medicaid agency and the exchange are supposed to share data and issue a “combined eligibility notice” for all types of assistance.

But the administration said this requirement would be delayed to Jan. 1, 2015, because more time was needed to establish electronic links between Medicaid and the exchanges.

Leonardo D. Cuello, who represents Medicaid beneficiaries as a lawyer at the National Health Law Program, expressed concern.

“Under the proposed rule,” Mr. Cuello said, “many people will be funneled into health insurance exchanges even though they have special needs that are better met in Medicaid. And if you asked the right questions, you would find out that they are eligible for Medicaid.”

The federal government will have the primary responsibility for running exchanges in more than half the states. About 20 states are expected to expand Medicaid; governors in other states are opposed or uncommitted.

The proposed rule allows hospitals to decide, “on the basis of preliminary information,” whether a person is eligible for Medicaid. States must provide immediate temporary coverage to people who appear eligible.

Kenneth E. Raske, president of the Greater New York Hospital Association, said this could be a boon to low-income people. “Currently,” he said, “only children and pregnant women are presumed eligible for inpatient admissions under Medicaid in New York.”

The public has until Feb. 13 to comment on the proposed rule. Comments can be submitted at www.regulations.gov.

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Even with record sales, Apple's earnings report may disappoint

If all goes according to plan Wednesday, Apple Inc. will report record revenue. The company will reveal that it sold more iPhones than in any previous quarter. And it will confirm that it hauled in another boatload of cash to swell its overflowing coffers.

In other words, Apple's earnings have all the makings of a colossal disaster.

That's because no matter how mind-blowing its performance, there is growing concern among investors that Apple's remarkable run of smartphone dominance is coming to an end. Although analysts' estimates for the company are all over the map, there is general agreement that Apple will not grow at nearly the same pace as it has over the last five years.

But after months of speculation and countless rumors that has helped drive the company's stock down 28% from its September peak, there is still widespread disagreement about how much that growth will slow and whether investors should be alarmed.

With observers desperate to finally hear what Apple executives have to say, the company's earnings report scheduled after the market closes Wednesday has become one of its most pivotal and highly anticipated in years.

Ben Reitzes, an analyst at Barclays, sent a recent note about Apple's earnings to clients under the title "Preparing for the Most Important Conference Call in Years."

Quiz: What set the Internet on fire in 2012?

"We believe that investor sentiment is quite negative right now for Apple, with significant concerns around demand trends for the iPhone 5," he wrote.

How investors adjust to that reality of slower growth is hard to predict. Will it be interpreted as a sign of weakness? Or just the reality that as a company gets bigger its pace of growth will inevitably slow?

First, the numbers. In October, Apple told Wall Street analysts that for its first quarter, which ended in December, investors should expect the company to report $52 billion in revenue and earnings of $11.75 a share.

But Apple tends to be notoriously conservative in its own guidance. For the same quarter a year earlier, Apple beat revenue estimates by more than 25% and earnings forecasts by nearly 50%. The surprising quarterly performance sent its stock into the stratosphere over the next nine months, eventually hitting an all-time high of $702.10 in September.

Such a huge surprise seems unlikely this time around. The consensus among Wall Street analysts is that Apple will report $54.7 billion in revenue and $13.41 a share in earnings. If the latter figure proves correct, that would represent a decline from the $13.87 a share in earnings that Apple reported for the same quarter last year. Not only would it be the first drop in a decade, but it also could confirm fears that Apple's new mix of products, including the iPad Mini, are hurting the company's historically high profit margins.

Making this all the more complicated is a quirk in the calendar. Last year, the same quarter had 14 weeks. This year, it has only 13 weeks. That means once the numbers are released, analysts and investors will have to do some fast calculations to make comparisons that are truly apples to apples.

In addition to worries about profit margins, investors have been fretting over rumors that the iPhone 5 has not been selling as well as expected, that rival Samsung Electronics Co. is widening its lead in smartphone sales, and that Apple's product upgrades don't dazzle like they once did. Of course, much of this is conjecture. But it has muddled projections, with analysts predicting that Apple could report earnings from as low as $11.53 a share to as much as $15.50 a share.

That kind of uncertainty has made investors even more eager than usual to hear any news about Apple's performance. Even more important than the numbers, however, is what Apple executives say about the future.

Since last summer, analysts have been growing more pessimistic about the current fiscal year, which ends in September, lowering their earnings projections to $48.86 a share from $54.87 a share in July. Should Apple lower that outlook further in the conference call Wednesday, it could trigger panic among Apple's investors.

"I think the concerns being reflected in the stock today have more to do with the next quarter than this one," said Walter Piecyk, a research analyst at BTIG.

To some analysts, the gloom over Apple's prospect is simply absurd. The value of the stock, trading at about 11 times earnings, is low by historical standards. Its price-to-earnings ratio hasn't been this low in more than five years, a period in which it has hovered between 15 and 20 times earnings.

And according to research firm Bespoke Investment Group, Apple is currently trading further below the consensus target ($728.36) than any of the other 100 largest stocks in the S&P 500. Apple on Tuesday closed up $4.77, or 1%, to $504.77‎.

In this view, the world's most valuable company is trading at bargain basement prices.

"There's nothing wrong with their business," said Colin Gillis, director of research at BGC Financial. "It's just a question of whether growth is going to slow. That had to happen eventually."

chris.obrien@latimes.com

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