Emergency Visits Seen Increasing With Health Law

The study, published in the journal Science, compared thousands of low-income people in the Portland area who were randomly selected in a 2008 lottery to get Medicaid coverage with people who entered the lottery but remained uninsured. Those who gained coverage made 40 percent more visits to the emergency room than their uninsured counterparts during their first 18 months with insurance.

The pattern was so strong that it held true across most demographic groups, times of day and types of visits, including those for conditions that were treatable in primary care settings.

The findings cast doubt on the hope that expanded insurance coverage will help rein in emergency room costs just as more than two million people are gaining coverage under the Affordable Care Act. And they go against one of the central arguments of the law’s supporters, that extending insurance to large numbers of Americans would reduce emergency room use, and eventually save money.

In remarks in New Mexico in 2009, Mr. Obama said: “I think that it’s very important that we provide coverage for all people because if everybody’s got coverage, then they’re not going to the emergency room for treatment.”

The study suggests that the surge in the numbers of insured people may put even greater pressure on emergency rooms, at least in the short term. Nearly 25 million uninsured Americans could gain coverage under the law, about half of them through Medicaid. The first policies took effect on Wednesday.

“I suspect that the finding will be surprising to many in the policy debate,” said Katherine Baicker, an economist at Harvard University’s School of Public Health and one of the authors of the study.

An administration spokeswoman, Tara McGuinness, said that the time frame was too short to expect much of a change, and that over the longer term, use would most likely decline. She pointed to a longer-term study in Massachusetts, which expanded coverage for its residents in 2006, that found an 8 percent decline in emergency department use over a period of several years.

“Medicaid saves lives and improves health outcomes,” Ms. McGuinness said. “Plenty of studies show that.”

But many economists say that the emphasis on emergency room use, both in policy and in political speeches, is misplaced, as it makes up only a small part of health care costs in the United States. A federal government health survey found that emergency departments accounted for about 4 percent of total health spending in 2010, far less than inpatient hospital visits, which accounted for about 31 percent. Certain populations, however, like low-income people with chronic illnesses, have much higher rates of use.

Dr. Baicker and Amy Finkelstein, an economist at the Massachusetts Institute of Technology, another author, said the increased use of emergency rooms is driven by a basic economic principle: When services get less expensive, people use them more. Previous studies have found that uninsured people face substantial out-of-pocket costs that can put them in debt when they go to the emergency room. Medicaid reduces those costs.

Medicaid coverage also reduces the costs of going to a primary care doctor, and a previous analysis of data from the Oregon experiment found that such visits also increased substantially.

“This is just one piece of an increase we found across every type of care,” said Bill J. Wright, an author of the new study who is the associate director of the Center for Outcomes Research and Education in Portland, a part of Providence Health and Services, a large health care provider.

The study’s authors emphasized that Medicaid had many benefits. Previous analyses from the experiment found that gaining coverage reduced the incidence of depression and increased feelings of financial stability.

The study drew on data from the Oregon Health Insurance Experiment that included about 90,000 low-income Oregonians and randomly assigned about 30,000 of them access to Medicaid. Health experts say the experiment’s design — random assignment of coverage through a lottery — allowed them to isolate and evaluate the effects of the program. Such designs are the gold standard in medical research, but are rarely used for domestic health care policy.

Superficial Visits and Trickery Undermine Foreign Factory Inspections

But unknown to the inspectors, none of the playful items, including reindeer suits and Mrs. Claus dresses for dogs, that were supplied to Walmart had been manufactured at the factory. Instead, Chinese workers sewed the goods, ordered by the Quaker Pet Group, based in New Jersey, at a rogue factory that had not gone through the certification process set by Walmart for labor, worker safety or quality, according to documents and interviews with officials involved.

To receive approval for shipment to Walmart, a Quaker subcontractor just moved the items over to the approved factory, where they were presented to inspectors as though they had been stitched together there and never left the premises.

Soon after the merchandise reached Walmart stores, it began falling apart.

Fifteen hundred miles to the west, the Rosita Knitwear factory in northwestern Bangladesh — which made sweaters for companies across Europe — passed an inspection audit with high grades. A team of four monitors gave the factory hundreds of approving check marks. In all 12 major categories, including working hours, compensation, management practices and health and safety, the factory received the top grade of “good.” “Working Conditions — No complaints from the workers,” the auditors wrote.

Ten months after that inspection, Rosita’s workers rampaged through the factory in February 2012, vandalizing its machinery and accusing management of reneging on promised raises, bonuses and overtime pay. Some claimed that they had been sexually harassed or beaten by guards. Not a hint of those grievances was reported in the audit.

As Western companies overwhelmingly turn to low-wage countries far away from corporate headquarters to produce cheap apparel, electronics and other goods, factory inspections have become a vital link in the supply chain of overseas production.

An extensive examination by The New York Times reveals how the inspection system intended to protect workers and ensure manufacturing quality is riddled with flaws. The inspections are often so superficial that they omit the most fundamental workplace safeguards like fire escapes. And even when inspectors are tough, factory managers find ways to trick them and hide serious violations, like child labor or locked exit doors. Dangerous conditions cited in the audits frequently take months to correct, often with little enforcement or follow-through to guarantee compliance.

Dara O’Rourke, a global supply chain expert at the University of California, Berkeley, said little had improved in 20 years of factory monitoring, especially with increased use of the cheaper “check the box” inspections at thousands of factories. “The auditors are put under greater pressure on speed, and they’re not able to keep up with what’s really going on in the apparel industry,” he said. “We see factories and brands passing audits but failing the factories’ workers.”

Still, major companies including Walmart, Apple, Gap and Nike turn to monitoring not just to check that production is on time and of adequate quality, but also to project a corporate image that aims to assure consumers that they do not use Dickensian sweatshops. Moreover, Western companies now depend on inspectors to uncover hazardous work conditions, like faulty electrical wiring or blocked stairways, that have exposed some corporations to charges of irresponsibility and exploitation after factory disasters that killed hundreds of workers.

The Rana Plaza factory collapse in Bangladesh, which killed 1,129 workers in April, intensified international scrutiny on factory monitoring, and pressured the world’s biggest retailers to sign onto agreements to tighten inspection standards and upgrade safety measures. While many groups consider the accords a significant advance, some longtime auditors and labor groups voice skepticism that inspection systems alone can ensure a safe workplace. After all, they say, the number of audits at Bangladesh factories has steadily increased as the country has become one of the world’s largest garment exporters, and still 1,800 workers there have died in workplace disasters in the last 10 years.

“We’ve been auditing factories in Bangladesh for 20 years, and I wonder, ‘Why aren’t these things changing? Why aren’t things getting better?’ ” said Rachelle Jackson, the director of sustainability and innovation at Arche Advisors, a monitoring group based in California.

Keith Bradsher contributed reporting.

Zuckerberg Visits Russia and Meets With Medvedev

MOSCOW — The hoodie stayed back at the hotel when Mark Zuckerberg, the founder of Facebook, met Russia’s prime minister and former president, Dmitri A. Medvedev, on Monday.

“Good conversation with Prime Minister Medvedev,” Mr. Zuckerman wrote on his Facebook wall beside a picture of the two, in suits and grinning, at the Russian leader’s residence outside Moscow.

Mr. Zuckerberg also visited Red Square — in his hoodie — ate at McDonald’s and helped judge a competition for Russian programmers under way in Moscow in his first visit to Russia, a country that is in important ways pivotal for Facebook.

One of Google’s founders, Sergey Brin, is Russian by birth. For Facebook, the tie is more oblique: The country is an important test case for the balancing act Facebook is undertaking as a new media company in countries that are important commercially but have traditionally heavily regulated their old media, if not censored it. And two of Facebook’s largest investors are Russian.

Mr. Zuckerberg and Mr. Medvedev talked about Facebook’s role in politics, though only jokingly in reference to its importance in the American presidential campaign, according to Mr. Medvedev’s press office.

They also discussed copyright rules and high-tech business. Mr. Zuckerberg gave the Russian leader a T-shirt; the meeting lasted about 20 minutes.

Facebook, in Russia as elsewhere, plays a double role as a tool for posting silly party pictures and a tool for political organizing.

Facebook played an integral role in political dissent in Russia last winter, allowing street protests to coalesce when handing out fliers or posting notices on corkboards would not have worked.

Russia is also home to two large and early Facebook investors, Alisher Usmanov, a steel tycoon, and Yuri Milner, an expert on monetizing social network traffic in emerging markets. The two partly cashed out in the initial public offering of Facebook stock earlier this year but still own billions of dollars’ worth of shares.

More Russians are online today than Germans, making Russia the largest Internet market in Europe. Russians also, strangely, have spent more freely relative to their income than Americans on virtual products, like special powers for online games, making their country a useful market for testing revenue streams other than advertising.

Earlier this month, in another step deeper into the Russian market, Facebook made a deal with one of Russia’s mobile phone operators, Beeline, to provide a free application to subscribers.

The Russian government, led by Mr. Medvedev, a technology lover, has embraced the Internet for its commercial potential even as it has been subtly trying to rein in the politics.

Such features as most-viewed lists of blogs, for example, are frowned on at Russian-run sites beholden to the Kremlin, lest a critical text go viral based on user approval.

In its prospectus for the initial public offering, Facebook had cautioned of the business risk of being banned from foreign markets, as it has been in China by the “Great Firewall.”

For now, Russia’s Internet is mostly unfettered.

In that spirit, pictures of the Facebook founder’s dog, Beast, which he posts on his Facebook page, became the topic of conversation in an episode Mr. Zuckerberg filmed for a Russian late-night comedy show on Monday.