Unemployment in Euro Zone Reached New High in October

BRUSSELS — Joblessness in the euro zone reached a new record in October, with another 173,000 people out of work, but consumer prices dropped sharply in November and offered some relief to households during the recession.

Annual inflation in the euro zone was 2.2 percent in November, the European Union’s statistics office, Eurostat, said on Friday, dropping from 2.5 percent in October.

Months of stubborn inflation combined with record unemployment have made life even harder for indebted families struggling through three years of a public debt crisis that has forced governments and companies to drastically cut jobs.

One of the smallest rises in energy price inflation in a year helped bring consumer inflation to near the European Central Bank’s target of 2 percent, according to Eurostat’s first estimate.

But the euro zone economy, which this year sank into its second recession since 2009, may manage only a weak recovery next year and unemployment levels will continue to rise, economists and policymakers say.

“We have not yet emerged from the crisis,” the European Central Bank president, Mario Draghi, said on Friday. “The recovery for most of the euro zone will certainly begin in the second half of 2013,” he told France’s Europe 1 radio.

Unemployment rose to 11.7 percent in October, Eurostat said, up from 11.6 percent in September and a marked increase from the 9.9 percent level a year ago, leaving almost 19 million people out of a job.

Portugal, for instance, shed more than one in 20 public sector jobs in the first nine months of 2012, while employers ranging from car makers to financial groups have announced thousands of job cuts since September.

Still, the overall number masks wide divergences across the 17-nation bloc, with Austrian unemployment running at 4.3 percent of the working population and Spain’s joblessness levels at 26.2 percent, the highest in Europe.

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Adkins explains Confederate flag earpiece

NEW YORK (AP) — Trace Adkins wore an earpiece decorated like the Confederate flag when he performed for the Rockefeller Center Christmas Tree Lighting but says he meant no offense by it.

Adkins appeared with the earpiece on a nationally televised special for the lighting on Wednesday. Some regard the flag as a racist symbol and criticized Adkins in Twitter postings.

But in a statement released Thursday, the Louisiana native called himself a proud American who objects to any oppression and says the flag represents his Southern heritage.

He noted he's a descendant of Confederate soldiers and says he did not intend offense by wearing it.

Adkins — on a USO tour in Japan — also called for the preservation of America's battlefields and an "honest conversation about the country's history."

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Online:

http://www.traceadkins.com

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The New Old Age Blog: Forced to Choose: Nursing Home vs. Hospice

An older person, someone who will die within six months, leaves a hospital. Where does she go?

Almost a third of the time, according to a recent study from the University of California, San Francisco, records show she takes advantage of Medicare’s skilled-nursing facility benefit and enters a nursing home. But is that the best place for end-of-life care?

In terms of monitoring her vital signs and handling IVs — the round-the-clock nursing care the skilled-nursing facility benefit is designed to provide — maybe so. But for treating end-of-life symptoms like pain and shortness of breath, for providing spiritual support for her and her family, for palliative care that helps her through the ultimate transition – hospice is the acknowledged expert.

She could receive hospice care, also covered by Medicare, while in the nursing home. But since Medicare only rarely reimburses for both hospice and the skilled-nursing facility benefit at the same time, this hypothetical patient and her family face a financial bind. If she opts for the hospice benefit, which does not include room and board at the nursing home, then she will be on the hook for hundreds of dollars a day to remain in the facility.

She could use the hospice benefit at home, of course. But, “we know these patients are medically complex,” said Katherine Aragon, lead author of the study in The Archives of Internal Medicine, and now a palliative care specialist at Lawrence General Hospital in Massachusetts. “And we know that taking care of someone near the end of life can be very demanding, hard for families to manage at home.” And that assumes the patient has a family or a home.

For some patients, a nursing home, though possibly dreaded, is the only place that can provide 24/7 care.

But if she uses the skilled-nursing facility benefit to pay for room and board in a facility, she probably has to forgo hospice. (The exception: if she was hospitalized for something unrelated to her hospice diagnosis. If she has cancer, then trips and breaks a hip, she can have both nursing home coverage and hospice. If cancer itself caused the bone to fracture, no dice.)

Let’s acknowledge that these are lousy choices.

The study, using data from the National Health and Retirement Study from 1994 through 2007, looked at more than 5,000 people who initially lived in the community – that is, not in a facility. About 30 percent used the skilled-nursing facility benefit during the final six months of life; those people were likely to be over 85 and family members said, after their deaths, that they had expected them to die soon. (The benefit is commonly referred to as S.N.F., which people in the field pronounce as “sniff”).

The choice to use S.N.F. had ongoing repercussions. Almost 43 percent of those who used it died in a nursing home and almost 40 percent in a hospital. Just 11 percent died at home, though that is where most people prefer to die, studies repeatedly show.

Among those who didn’t use the S.N.F. benefit, more than 40 percent died at home.

In effect, nursing homes were providing end-of-life care, expensively and probably not so well, for almost a third of the elderly population.

The skilled-nursing facility benefit, Dr. Aragon pointed out in an interview, is meant to provide rehabilitation. “The hope is that someone will get stronger and go home,” she said.

Sometimes, of course, that is what happens.

“What we may be missing is that this patient is on an end-of-life trajectory,” she continued. “Maybe they can’t get stronger.”

Moreover, Dr. Aragon pointed out, nursing homes often have financial incentives to keep re-hospitalizing patients. After three days in a hospital, the skilled-nursing facility benefit starts anew, and it reimburses at a higher level than Medicaid, which pays for most nursing home care.

Because this unhappy choice between hospice care and nursing home reimbursement reflects federal policy, there may be little that individual families can do. If physicians are willing to honestly discuss their patients’ prognosis, to assess whether a nursing home stay will lead to rehabilitation or whether it is where a patient will likely die, sooner rather than later, families may have some personal options.

If they knew that death was likely within a few months, they might try to provide care at home with hospice help for that limited time, difficult as that is. Or they might be able to muster enough money to pay for a few months in a nursing home, so that their parent can be a resident and still receive hospice care.

But these are still lousy choices. “Palliative care should be part of nursing home care,” said Alexander K. Smith, the study’s senior author and a palliative care specialist at the University of California, San Francisco. “And that regulation that prevents concurrent use of the S.N.F. benefit and hospice isn’t in the interest of patients and families.”

Coming up in a future post: Experimenting with a concurrent-coverage option.

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

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Most Americans Face Lower Tax Burden Than in the 80s

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

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

Kirsten Luce for The New York Times

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Medicare Is Faulted in Electronic Medical Records Conversion

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

Mike Spencer/Wilmington Star-News, via Associated Press

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

Centers for Medicare and Medicaid Services

Marilyn Tavenner, acting administrator for Medicare.

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

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

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

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

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

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

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

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

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

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

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

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Tougher UAE Internet dissent law shuts door to free speech: HRW

DUBAI (Reuters) – The United Arab Emirates has “effectively closed the country’s remaining forum for free speech” with a decree issued earlier this month that tightened the law on online dissent, Human Rights Watch said on Wednesday.

The U.S.-allied UAE, a Gulf trading and tourism hub and big oil producer, has not seen the serious unrest that has toppled four Arab heads of state since early last year. But it has shown little tolerance of open dissent, and more than 60 members of an Islamist group have been detained since the start of the year.

The decree by President Sheikh Khalifa bin Zayed al-Nahayan imposes prison sentences for anyone who derides or caricatures the Gulf Arab country’s rulers or state institutions on the web, the state news agency WAM reported on November 12.

“The UAE’s cybercrimes decree reflects an attempt to ban even the most tempered criticism,” said Joe Stork, deputy Middle East director at Human Rights Watch.

“The determination to police and punish online dissent, no matter how mild, is incompatible with the image UAE rulers are trying to promote of a progressive, tolerant nation.”

A source close to the UAE government said on Wednesday the decree aimed to address technological advances in communications that could affect the rights and beliefs of people.

“This decree does not restrict freedom of expression, which is guaranteed by the UAE constitution,” the source said. “The decree represents an extension of legislation to cover a wide variety of potential offences in many fields, including terrorism, human trafficking, money laundering and identity theft.”

POSSIBLE PRISON TERMS

WAM said the amendments “stipulate penalties of imprisonment on any person who creates or runs an electronic website or uses any information technology medium to deride or damage the reputation or stature of the state or any of its institutions”.

This included the president, the vice president, any of the rulers of the seven emirates that make up the UAE, crown princes, deputy rulers, the national flag, the national anthem, the emblem of the state or any of its symbols.

Social networking sites have enlivened public discourse in the UAE, a major oil exporter and business hub, where state media are tightly controlled and freedom of speech restricted.

People across UAE society, from ruling family members to ministers, government supporters and dissidents, make use of sites such as Twitter and Facebook.

The amendments announced on November 12 cover a wide range of offences, including outlawing the use of the Internet for human trafficking and prostitution.

But they include jail terms for “any person publishing any information, news, caricatures or any other kind of pictures that would pose threats to the security of the state and to its highest interests or violate its public order,” said WAM.

In addition, anyone who uses the Internet “to call for demonstrations, marches and similar activities without a license being obtained in advance from the competent authorities” could also face imprisonment.

Human Rights Watch said the decree’s vaguely worded provisions provide a legal basis to prosecute and jail people who use information technology to criticize senior officials, demand political reforms or organize unlicensed demonstrations.

“Although some provisions are aimed at preventing the proliferation of racist or sectarian views online, the principal effect of the law is severe restrictions on the rights to free expression and free association and assembly,” the New York-based watchdog said.

(Reporting by Sami Aboudi; Editing by Mark Heinrich)

Internet News Headlines – Yahoo! News

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Lindsay Lohan arrested on assault charge in NYC

NEW YORK (AP) — Actress Lindsay Lohan was arrested Thursday after police said she hit a woman during an argument at a New York City nightclub.

The "Mean Girls" and "Freaky Friday" star was arrested at 4 a.m. and charged with third-degree assault.

She allegedly got into the spat with another woman at Club Avenue, in Manhattan's Chelsea section. She struck the woman in face with her hand, police said. The victim did not require medical attention.

Her publicist did not immediately return a call for comment.

The arrest is Lohan's latest brush with law enforcement in New York City.

She was involved in a NYPD investigation in September after alleging a man had assaulted her in a New York hotel, but charges against the man were later dropped.

Also in September, the actress was accused of clipping a man with her car outside another Manhattan nightclub, but prosecutors chose not to move ahead with charges.

In October, police were called to her childhood home on Long Island after a report of fight between her and her mother. An investigation revealed "no criminality."

The actress was also involved in a car accident in California this summer that sent her and an assistant to a hospital, but didn't result in serious injuries for anyone. The accident remains under investigation.

In May, she was cleared of allegations that she struck a Hollywood nightclub manager with her car.

Lohan remains on informal probation for taking a necklace from a jewelry store without permission last year. That means she doesn't have to check in with a judge or probation officer but could face a jail term if arrested again.

Her latest film, "Liz & Dick," in which she portrays screen icon Elizabeth Taylor, premiered on Lifetime on Sunday.

Lohan also recently filmed "The Canyons," an indie film written by "Less Than Zero" and "American Psycho" author Bret Easton Ellis.

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Cost of Brand-Name Prescription Medicines Soaring

The price of brand-name prescription medicines is rising far faster than the inflation rate, while the price of generic drugs has plummeted, creating the largest gap so far between the two, according to a report published Wednesday by the pharmacy benefits manager Express Scripts.

The report tracked an index of commonly used drugs and found that the price of brand-name medicines increased more than 13 percent from September 2011 to this September, which it said was more than six times the overall price inflation of consumer goods. Generic drug prices dipped by nearly 22 percent.

The drop in the price of generics “represents low-hanging fruit for the country to save money on health care,” said Dr. Steve Miller, the chief medical officer of Express Scripts, which manages the drug benefits for employers and insurers and also runs a mail-order pharmacy.

The report was based on a random sample of six million Express Scripts members with prescription drug coverage.

The Pharmaceutical Research and Manufacturers of America, the trade group representing brand-name manufacturers, criticized the report, saying it was skewed by a handful of high-priced specialty drugs that are used by a small number of patients and overlooked the crucial role of major drug makers.

“Without the development of new medicines by innovator companies, there would be neither the new treatments essential to progress against diseases nor generic copies,” Josephine Martin, executive vice president of the group, said in a statement.

The report cited the growth of specialty drugs, which treat diseases like cancer and multiple sclerosis, as a major reason for the increase in spending on branded drugs. Spending on specialty medicines increased nearly 23 percent during the first three quarters of 2012, compared with the same period in 2011. All but one of the new medicines approved in the third quarter of this year were specialty drugs, the report found, and many of them were approved to treat advanced cancers only when other drugs had failed.

Stephen W. Schondelmeyer, a professor of pharmaceutical economics at the University of Minnesota, said the potential benefits of many new drugs did not always match the lofty price tags. “Increasingly it’s going to be difficult for drug-benefit programs to make decisions about coverage and payment and which drugs to include,” said Mr. Schondelmeyer, who conducts a similar price report for AARP. He also helps manage the drug benefit program for the University of Minnesota.

“We’re going to be faced with the issue that any drug at any price will not be sustainable.”

Spending on traditional medicines — which treat common ailments like high cholesterol and blood pressure — actually declined by 0.6 percent during the period, the report found. That decline was mainly because of the patent expiration of several blockbuster drugs, like Lipitor and Plavix, which opened the market for generic competitors. But even as the entry of generic alternatives pushed down spending, drug companies continued to raise prices on their branded products, in part to squeeze as much revenue as possible out of an ever-shrinking portfolio, Dr. Miller said.

Drug makers are also being pushed by companies like Express Scripts and health insurers, which are increasingly looking for ways to cut costs, said C. Anthony Butler, a pharmaceuticals analyst at Barclays. “I think they’re pricing where they can but what they keep telling me is they’re under significant pressure” to keep prices low, he said.

Express Scripts earns higher profits from greater use of generic medicines than brand name drugs sold through their mail-order pharmacy, Mr. Butler said. “There’s no question that they would love for everybody to be on a generic,” he said.

Dr. Miller acknowledged that was true but said that ultimately, everyone wins. “When we save people money, that’s when we make money,” he said. “We don’t shy away from that.”

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

Luke Sharrett for The New York Times

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

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

Luke Sharrett for The New York Times

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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News Analysis: Sunni Leaders Gaining Clout in Mideast

Mohammed Saber/European Pressphoto Agency

A Palestinian woman in Gaza City on Tuesday walked amid the rubble left from eight days of fighting that ended in a cease-fire.

RAMALLAH, West Bank — For years, the United States and its Middle East allies were challenged by the rising might of the so-called Shiite crescent, a political and ideological alliance backed by Iran that linked regional actors deeply hostile to Israel and the West.

But uprising, wars and economics have altered the landscape of the region, paving the way for a new axis to emerge, one led by a Sunni Muslim alliance of Egypt, Qatar and Turkey. That triumvirate played a leading role in helping end the eight-day conflict between Israel and Gaza, in large part by embracing Hamas and luring it further away from the Iran-Syria-Hezbollah fold, offering diplomatic clout and promises of hefty aid.

For the United States and Israel, the shifting dynamics offer a chance to isolate a resurgent Iran, limit its access to the Arab world and make it harder for Tehran to arm its agents on Israel’s border. But the gains are also tempered, because while these Sunni leaders are willing to work with Washington, unlike the mullahs in Tehran, they also promote a radical religious-based ideology that has fueled anti-Western sentiment around the region.

Hamas — which received missiles from Iran that reached Israel’s northern cities — broke with the Iranian axis last winter, openly backing the rebellion against the Syrian president, Bashar al-Assad. But its affinity with the Egypt-Qatar-Turkey axis came to fruition this fall.

“That camp has more assets that it can share than Iran — politically, diplomatically, materially,” said Robert Malley, the Middle East program director for the International Crisis Group. “The Muslim Brotherhood is their world much more so than Iran.”

The Gaza conflict helps illustrate how Middle Eastern alliances have evolved since the Islamist wave that toppled one government after another beginning in January 2011. Iran had no interest in a cease-fire, while Egypt, Qatar and Turkey did.

But it is the fight for Syria that is the defining struggle in this revived Sunni-Shiite duel. The winner gains a prized strategic crossroads.

For now, it appears that that tide is shifting against Iran, there too, and that it might well lose its main Arab partner, Syria. The Sunni-led opposition appears in recent days to have made significant inroads against the government, threatening the Assad family’s dynastic rule of 40 years and its long alliance with Iran. If Mr. Assad falls, that would render Iran and Hezbollah, which is based in Lebanon, isolated as a Shiite Muslim alliance in an ever more sectarian Middle East, no longer enjoying a special street credibility as what Damascus always tried to sell as “the beating heart of Arab resistance.”

If the shifts seem to leave the United States somewhat dazed, it is because what will emerge from all the ferment remains obscure.

Clearly the old leaders Washington relied on to enforce its will, like President Hosni Mubarak of Egypt, are gone or at least eclipsed. But otherwise confusion reigns in terms of knowing how to deal with this new paradigm, one that could well create societies infused with religious ideology that Americans find difficult to accept. The new reality could be a weaker Iran, but a far more religiously conservative Middle East that is less beholden to the United States.

Already, Islamists have been empowered in Egypt, Libya and Tunisia, while Syria’s opposition is being led by Sunni insurgents, including a growing number identified as jihadists, some identified as sympathizing with Al Qaeda. Qatar, which hosts a major United States military base, also helps finance Islamists all around the region.

In Egypt, President Mohamed Morsi resigned as a member of the Muslim Brotherhood only when he became head of state, but he still remains closely linked with the movement. Turkey, the model for many of them, has kept strong relations with Washington while diminishing the authority of generals who were longstanding American allies.

“The United States is part of a landscape that has shifted so dramatically,” said Mr. Malley of the International Crisis Group. “It is caught between the displacement of the old moderate-radical divide by one that is defined by confessional and sectarian loyalty.”

The emerging Sunni axis has put not only Shiites at a disadvantage, but also the old school leaders who once allied themselves with Washington.

The old guard members in the Palestinian Authority are struggling to remain relevant at a time when their failed 20-year quest to end the Israeli occupation of Palestinian lands makes them seem both anachronistic and obsolete.

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