Feds OK insurance exchange partnership

Health and Human Services Secretary Kathleen Sebelius on Wednesday said her department conditionally approved Illinois’ plan to operate a health insurance exchange in a partnership with the federal government, a widely expected move that makes the state the third to receive the official go ahead. 

Sebelius plans to make the announcement Wednesday afternoon at a West Side clinic alongside Gov. Pat Quinn, Sebelius said the approval will allow the state and the federal government to continue work on readying the online marketplace for Oct. 1, when uninsured Illinoisans can begin signing up for health insurance offered under the 2010 health care overhaul law.

Under the partnership model, Illinois will maintain its responsibility for regulating the insurance market, a function that will allow the state to tailor the types of private health insurance plans offered through the exchange. Illinois also will be in charge of customer assistance, which will allow it to conduct outreach efforts and aid people in signing up.

The federal government is responsible for building and operating the exchange.

Illinois becomes the third state to have its partnership plan approved, following Delaware and Arkansas. A handful of other states, including Iowa, Michigan, West Virginia and New Hampshire, also are interested in the partnership model. Other states have opted to set up and run their own exchanges, while a majority refused to participate, relying on the federal government to do so.

Sebelius is in town through Thursday to meet with several large stakeholders, including union leaders, clergy and community groups, to raise awareness about the forthcoming exchanges, a spokesman said.

The exchanges are a crucial part of the government's plan to expand the number of Americans who have some form of health insurance.

Eventually, an estimated 20 million people will benefit from federal tax credits starting in 2014 that will help offset the cost of paying for insurance premiums. Even so, the government estimates that about 6 million Americans will not sign up and will start paying tax penalties in 2014.

In the first year, those penalties are relatively modest, starting at $95 for adults and $47.50 per child. But they’re expected to increase in future years, eventually totaling nearly $7 billion in 2016, an average fine of about $1,200 per person.

While states were given the option of setting up and running their own exchanges, only 18 chose to do so, with most of the rest opting to allow the federal government to operate them, at least in the beginning.

Julie Hamos, director of the state Department of Healthcare and Family Services, has said she hopes to get legislation passed this spring to authorize a purely state-run exchange that will be up and ready in time for open enrollment for 2015.

Meanwhile, consumers can expect a marketing blitz during the summer and into the fall touting the exchanges, which will serve individuals who are not eligible for Medicare or Medicaid and not offered health insurance through their employers.

pfrost@tribune.com | Twitter: @peterfrost

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Fugitive ex-cop surrounded by police in cabin after gun battle

Christopher Dorner was engaged in a shootout with federal authorities in the Big Bear area Tuesday, a law enforcement source told The Times.

"Hundreds of rounds" were exchanged in about half an hour during the gun battle between fugitive former police officer Christopher Dorner and law enforcement officers Tuesday afternoon, sources said.

At least two San Bernardino County sheriff's deputies were wounded, sources said. Their conditions were not immediately known.

Days ago, Dorner broke into a cabin off Route 38, a source said. He allegedly tied up the couple inside and held them hostage until Tuesday morning when he left. It is unclear whether Dorner stole their vehicle or another, but Fish and Wildlife officers knew to be on the lookout for a white pickup truck when they spotted Dorner driving one and attempted to stop him, the source said.

Dorner crashed the truck during the ensuing chase and allegedly exchanged gunfire with the officers as he fled into another cabin, where he was quickly surrounded by San Bernardino sheriff’s deputies. The source said one deputy was hit as Dorner fired out of the cabin and a second was injured when Dorner exited the back of the cabin, deployed a smoke bomb and opened fire again in an apparent attempt to flee. Dorner was driven back inside the cabin, the source said.

There was initial confusion as to where a helicopter should land to evacuate the injured officers,  so deputies used their own smoke bombs to provide enough cover to carry the wounded to a pickup truck that took them to the waiting helicopter.

Officers have crisscrossed California for days pursuing the more than 1,000 tips that poured in about Dorner's possible whereabouts — including efforts in Tijuana, Mexico, San Diego County and Big Bear — and serving warrants at homes in Las Vegas and Point Loma.

Statewide alerts were issued in California and Nevada, and border authorities were alerted. The Transportation Security Administration also issued an alert urging pilots and other aircraft operators to keep an eye out for Dorner.

At the search's height, more than 200 officers scoured the mountain, conducting cabin-by-cabin checks. It was scaled back Sunday — about 30 officers were out in the field Tuesday, the San Bernardino County Sheriff's Department said.

Dorner allegedly threatened "unconventional and asymmetrical warfare" against police in a lengthy manifesto that authorities say he posted on Facebook. The posting named dozens of potential targets, including police officers, whom Dorner allegedly threatened to attack, according to authorities.

His alleged slayings began Feb. 3 with the deaths of Monica Quan, a Cal State Fullerton assistant basketball coach, and her fiance, Keith Lawrence, a USC public safety officer. Quan was the daughter of a retired LAPD captain whom Dorner allegedly blamed in part for his firing from the force in 2009.

While on the run Thursday, Dorner allegedly shot three police officers in Riverside County, killing one and wounding the others. Riverside Officer Michael Crain, 34, a married father of two who served two tours in Kuwait as a rifleman in the Marines, was killed in the attack.

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Well: Straining to Hear and Fend Off Dementia

At a party the other night, a fund-raiser for a literary magazine, I found myself in conversation with a well-known author whose work I greatly admire. I use the term “conversation” loosely. I couldn’t hear a word he said. But worse, the effort I was making to hear was using up so much brain power that I completely forgot the titles of his books.

A senior moment? Maybe. (I’m 65.) But for me, it’s complicated by the fact that I have severe hearing loss, only somewhat eased by a hearing aid and cochlear implant.

Dr. Frank Lin, an otolaryngologist and epidemiologist at Johns Hopkins School of Medicine, describes this phenomenon as “cognitive load.” Cognitive overload is the way it feels. Essentially, the brain is so preoccupied with translating the sounds into words that it seems to have no processing power left to search through the storerooms of memory for a response.

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Katherine Bouton speaks about her own experience with hearing loss.

A transcript of this interview can be found here.

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Over the past few years, Dr. Lin has delivered unwelcome news to those of us with hearing loss. His work looks “at the interface of hearing loss, gerontology and public health,” as he writes on his Web site. The most significant issue is the relation between hearing loss and dementia.

In a 2011 paper in The Archives of Neurology, Dr. Lin and colleagues found a strong association between the two. The researchers looked at 639 subjects, ranging in age at the beginning of the study from 36 to 90 (with the majority between 60 and 80). The subjects were part of the Baltimore Longitudinal Study of Aging. None had cognitive impairment at the beginning of the study, which followed subjects for 18 years; some had hearing loss.

“Compared to individuals with normal hearing, those individuals with a mild, moderate, and severe hearing loss, respectively, had a 2-, 3- and 5-fold increased risk of developing dementia over the course of the study,” Dr. Lin wrote in an e-mail summarizing the results. The worse the hearing loss, the greater the risk of developing dementia. The correlation remained true even when age, diabetes and hypertension — other conditions associated with dementia — were ruled out.

In an interview, Dr. Lin discussed some possible explanations for the association. The first is social isolation, which may come with hearing loss, a known risk factor for dementia. Another possibility is cognitive load, and a third is some pathological process that causes both hearing loss and dementia.

In a study last month, Dr. Lin and colleagues looked at 1,984 older adults beginning in 1997-8, again using a well-established database. Their findings reinforced those of the 2011 study, but also found that those with hearing loss had a “30 to 40 percent faster rate of loss of thinking and memory abilities” over a six-year period compared with people with normal hearing. Again, the worse the hearing loss, the worse the rate of cognitive decline.

Both studies also found, somewhat surprisingly, that hearing aids were “not significantly associated with lower risk” for cognitive impairment. But self-reporting of hearing-aid use is unreliable, and Dr. Lin’s next study will focus specifically on the way hearing aids are used: for how long, how frequently, how well they have been fitted, what kind of counseling the user received, what other technologies they used to supplement hearing-aid use.

What about the notion of a common pathological process? In a recent paper in the journal Neurology, John Gallacher and colleagues at Cardiff University suggested the possibility of a genetic or environmental factor that could be causing both hearing loss and dementia — and perhaps not in that order. In a phenomenon called reverse causation, a degenerative pathology that leads to early dementia might prove to be a cause of hearing loss.

The work of John T. Cacioppo, director of the Social Neuroscience Laboratory at the University of Chicago, also offers a clue to a pathological link. His multidisciplinary studies on isolation have shown that perceived isolation, or loneliness, is “a more important predictor of a variety of adverse health outcomes than is objective social isolation.” Those with hearing loss, who may sit through a dinner party and not hear a word, frequently experience perceived isolation.

Other research, including the Framingham Heart Study, has found an association between hearing loss and another unexpected condition: cardiovascular disease. Again, the evidence suggests a common pathological cause. Dr. David R. Friedland, a professor of otolaryngology at the Medical College of Wisconsin in Milwaukee, hypothesized in a 2009 paper delivered at a conference that low-frequency loss could be an early indication that a patient has vascular problems: the inner ear is “so sensitive to blood flow” that any vascular abnormalities “could be noted earlier here than in other parts of the body.”

A common pathological cause might help explain why hearing aids do not seem to reduce the risk of dementia. But those of us with hearing loss hope that is not the case; common sense suggests that if you don’t have to work so hard to hear, you have greater cognitive power to listen and understand — and remember. And the sense of perceived isolation, another risk for dementia, is reduced.

A critical factor may be the way hearing aids are used. A user must practice to maximize their effectiveness and they may need reprogramming by an audiologist. Additional assistive technologies like looping and FM systems may also be required. And people with progressive hearing loss may need new aids every few years.

Increasingly, people buy hearing aids online or from big-box stores like Costco, making it hard for the user to follow up. In the first year I had hearing aids, I saw my audiologist initially every two weeks for reprocessing and then every three months.

In one study, Dr. Lin and his colleague Wade Chien found that only one in seven adults who could benefit from hearing aids used them. One deterrent is cost ($2,000 to $6,000 per ear), seldom covered by insurance. Another is the stigma of old age.

Hearing loss is a natural part of aging. But for most people with hearing loss, according to the National Institute on Deafness and Other Communication Disorders, the condition begins long before they get old. Almost two-thirds of men with hearing loss began to lose their hearing before age 44. My hearing loss began when I was 30.

Forty-eight million Americans suffer from some degree of hearing loss. If it can be proved in a clinical trial that hearing aids help delay or offset dementia, the benefits would be immeasurable.

“Could we do something to reduce cognitive decline and delay the onset of dementia?” he asked. “It’s hugely important, because by 2050, 1 in 30 Americans will have dementia.

“If we could delay the onset by even one year, the prevalence of dementia drops by 15 percent down the road. You’re talking about billions of dollars in health care savings.”

Should studies establish definitively that correcting hearing loss decreases the potential for early-onset dementia, we might finally overcome the stigma of hearing loss. Get your hearing tested, get it corrected, and enjoy a longer cognitively active life. Establishing the dangers of uncorrected hearing might even convince private insurers and Medicare that covering the cost of hearing aids is a small price to pay to offset the cost of dementia.

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Katherine Bouton is the author of the new book, “Shouting Won’t Help: Why I — and 50 Million Other Americans — Can’t Hear You,” from which this essay is adapted.

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This post has been revised to reflect the following correction:

Correction: February 12, 2013

An earlier version of this article misstated the location of the Medical College of Wisconsin. It is in Milwaukee, not Madison.

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Chicago leads nation in gas-price spikes

Drivers in Chicago are seeing a painful rise in gas prices get even worse this month.

The average price of regular unleaded in the Chicago metro area on Tuesday is $3.93, according to AAA. That's up 12 cents from a week ago. A month ago, the average was $3.42. Statewide, the average is about $3.79, up 8 cents from last week and 46 cents last month.

Prices are rising at pumps across the country, too, but not as dramatically. The national average is $3.60, up about 7 cents from a week ago and 30 cents higher than this time last month.

It's not typical to see gas price spikes at this time of year. Demand is typically low and picks up in the spring before driving season. And in general, gas is cheaper to produce in the winter because refineries can use less expensive blends.

The main reason for the spike is the higher price of crude oil. The price of oil has gone from around $85 a barrel in December to around $97 now because of improving economic certainty as the country moved past the election and the fiscal cliff deadline, according to energy analyst Phil Flynn. It's also being driven by better-than-expected growth in China, the world's second largest economy.

Prices in the Chicago area are typically some the highest in the nation, but the cost of a local fill-up is accelerating at almost double the national rate.

Flynn attributes this to a number of refinery issues in the region. Some scheduled maintenance at refineries -- where gasoline and other products are produced from oil -- occurred earlier than usual, which cut off some supply, affecting prices. Many close at this time of year to start the switchover to lower-emission summer blends of gasoline.

Besides a major overhaul of BP's Whiting refinery, the largest supplier of gasoline to Midwest markets, that's believed to be driving prices higher, a fire temporarily shut down a refinery in northwest Ohio.

AAA, which tracks daily gasoline prices around the country, predicts they will continue their rapid climb as local refinery issues continue into the beginning of peak driving season.

Flynn is more optimistic.

He believes that once the major Whiting refinery overhaul is complete later this year, gas prices will stabilize.

"I'm probably in the minority but I think we are starting to see some light at the end of the tunnel," he said.

sbomkamp@tribune.com | Twitter: @SamWillTravel

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Cardinal George praises pope's 'courage' in resigning

Cardinal Francis George said he was as surprised as everyone else when Pope Benedict XVI announced he was stepping down, saying he saw the pontiff briefly last week in Rome and “there was not the slightest indication in my mind.”

But George added during a news conference that Benedict "looks like a man who’s feeling the weight of his years.”

The cardinal, who will return to Rome to elect a new pope, said Benedict's public role was a particular burden.

"It the public role that the most effort for him and takes the most energy from him," George said, calling Benedict an introvert. "He gets tired in big crowds. . .The teaching, the decision-making [is] relatively easy in comparison to the public role."

Earlier, in a statement, George said Benedict "placed the will of God for the good of the church before every other consideration" when he decided to resign.

"He has taught with clarity and charity what God has revealed to the world in Christ, he has handed on the apostolic faith, he has loved all of God’s people with all his heart," George said in a statement. "He has now shown great courage in deciding, after prayer and soul-searching, to resign his office at the end of this month.
 
"With the gratitude of sons and daughters in our hearts, we ask the Lord to bless him and give him strength, as we begin to pray now for the one who will succeed him as Bishop of Rome, Successor of Peter and Vicar of Christ."

Joliet Bishop Daniel Conlon said the pope's decision "is consistent with the humble disposition that I have come to recognize in him, both in my brief personal encounters with him and in his deportment generally as earthly shepherd of the church.

"He recognized that he no longer had the physical gifts necessary to carry out an office that becomes increasingly demanding," Conlon said. "He has been a steady and calm presence in the face of tumult in the world.  He has persevered in Blessed John Paul II’s determination to confront the scandal of child abuse in the church."

Benedict shocked the world by saying he no longer had the mental and physical strength to cope with his ministry, in an announcement that left his aides "incredulous" and will make him the first pontiff to step down since the Middle Ages.

The German-born pope, 85, admired as a hero by conservative Roman Catholics and viewed with suspicion by liberals, told cardinals in Latin that his strength had deteriorated recently. He will step down on Feb. 28 and the Vatican expects a new Pope to be chosen by the end of March.

Vatican spokesman Father Federico Lombardi said the pope had not decided to resign because of "difficulties in the papacy" and the move had been a surprise, indicating that even his inner circle was unaware that he was about to quit.

A priest at St. Peter's Church in the Loop said the news is "surprising but not terrifying," saying it will allow the church to continue to renew itself.

“It’s a new beginning and a chance for new energy in the church,” said the Rev. Ed Shea. "This is good news.”

The selection of a new pope will offer the church the chance to continue its emergence into the “the modern light, the modern world,” Shea said. 

It will also provide a chance to choose a pope from Africa or South America, he said, to reflect the growth of the church on those continents.

“I was shocked, like everybody else,” Father Ed Shea said.  “It kind of surprised me that we didn’t know about it ahead of time.”

As worshipers left a morning mass at St. Peter’s this morning, several said the pope’s announcement had caught them completely by surprise.

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Well: Picking Source of Baby's Milk

When Bevil Conway and his partner brought their premature twins home from the hospital, the two fathers felt it was important to keep them on a diet of breast milk. So the new parents purchased a couple of coolers and an extra freezer, and they started scouring Web sites for mothers with extra milk to share.

They found a physician who was moving away; she gave them a stash of frozen milk she had pumped but never needed. They stopped by a fire station in Lexington, Mass., to retrieve milk from a firefighter’s wife. They picked up 100 ounces from a woman whose husband wanted his freezer back before hunting season, and they made regular visits to a woman in Maine who became a close friend and produced startling, prodigious amounts of milk.

And all of it was free.

“It was amazing, absolutely amazing,” said Dr. Conway, 38, a neuroscientist and artist in Cambridge, Mass. “We managed to feed the twins continuously without any formula for 14 months.”

Wet nursing has moved into the Internet age. Where once new parents desperate for breast milk recruited a local mother or, more recently, turned to milk banks or made do with formula, now they rely on informal networks of donors, mostly strangers, hosted on Web sites like Eats on Feets and Human Milk 4 Human Babies.

But some physicians and public health experts fear that in their quest to provide infants with the benefits of breast milk, new parents may inadvertently be exposing their babies to potential harm.

Breast milk confers enormous health benefits. It’s considered the ideal nutrition for infants, and it contains antibodies and other protective immune factors that appear to reduce colds, ear and gastrointesintal infections, asthma and eczema, as well as diabetes and even leukemia, according to the American Academy of Pediatrics. Neonatal intensive care units insist on breast milk for the smallest babies because it drastically improves their prospects.

But it is also a bodily fluid that can harbor harmful bacteria and viruses, including H.I.V., and H.I.V.-positive mothers can transmit the virus to their babies through their milk.

Established human milk banks carefully screen donors, test them for diseases and pasteurize the breast milk they provide. But there is a huge demand for milk — in 2012 the banks dispensed 2.5 million ounces of milk, up from 2.1 million ounces in 2011 — and the banks must prioritize the smallest and sickest babies.

And the prices are steep. Breast milk can cost up to $5.50 an ounce, more than the cost of formula. A 3-month-old can drink anywhere from 20 to 40 ounces a day or more.

As a result, many new parents are turning to the Web, despite the Food and Drug Administration’s recommendation against feeding babies breast milk acquired directly from individuals or online.

“You don’t know what you’re getting on the Internet,” said Dr. Susan Landers, a neonatologist in Austin, Tex., one of several experts who in 2010 urged the Food and Drug Administration to step in and start regulating human milk banks. (The F.D.A. declined.)

Dr. Landers noted that even if donor mothers have tested negative for viruses and bacteria, they may drink alcohol, smoke marijuana or use medicine that can be passed on through breast milk.

When researchers reviewed the blood tests of 1,091 potential milk donors who had approached one milk bank over a recent six-year period, they found that 3.3 percent tested positive for a virus or bacterium on screening tests (some may have been false positives). Six were infected with syphilis, 17 with hepatitis B and three with hepatitis C. Six tested positive for human T-cell lymphotropic viruses (HTLV-1 and HTLV-2), and four were H.I.V.-positive.

Officials with milk banks also worry that informal milk sharing is robbing them of potential donors and could curtail the supply to premature babies. “Their lives can depend on receiving human milk,” said Kim Updegrove of the Human Milk Banking Association of North America. “And we don’t have enough. We are constantly cutting back on requests from hospitals.”

But many parents don’t even want pasteurized milk of the sort banks provide, because the heating process destroys some of the very substances — some of the milk’s immunoglobulin A, for example — that they are seeking in breast milk.

“We use it straight up,” Dr. Conway said. “We want all the antibodies.” He noted that the donors he encountered were always willing to provide their medical records and were always nursing their own babies.

So what’s a parent-to-be to do?

Pregnant women who want to breast-feed should plan for it, making sure their hospitals’ policies facilitate breast-feeding and allow a baby and mother to share a room. Pacifiers should be avoided.

If a baby is born prematurely and can’t nurse, breast milk should be pumped 10 to 12 times a day to establish a supply.

Parents who use donor milk from informal channels should ask about the health histories of the donors and for recent blood tests and medical records.

Dr. Landers suggested new parents also consider flash-heating donor milk, a technique that can inactivate H.I.V. and destroy bacteria while retaining much of the milk’s nutritional and antimicrobial properties and important antibodies.

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Maker's Mark lowering proof to meet demand

Maker's Mark announced it is reducing the amount of alcohol in the spirit to keep pace with rapidly increasing consumer demand.

In an email to its fans, representatives of the brand said the entire bourbon category is "exploding" and demand for Maker's Mark is growing even faster. Some customers have even reported empty shelves in their local stores, it said.

After looking at "all possible solutions," the total alcohol by volume of Maker's Mark is being reduced by 3 percent. Representatives said the change will allow it to maintain the same taste while making sure there's "enough Maker's Mark to go around." It's working to expand its distillery and production capacity, too.

Maker's Mark, made by Deerfield-based Beam Inc., said it's done extensive testing to ensure the same taste. It says bourbon drinkers couldn't tell the difference. It also underscored the fact that nothing else in the production process has changed.

"In other words, we've made sure we didn't screw up your whisky," the note said.

Rob Samuels, chief operating officer and grandson of Maker's Mark Founder Bill Samuels, Sr., said this is a permanent decision that won’t be reversed when demand for bourbon slows down. Samuels said that bourbon has gone from the slowest growing spirits category to the fastest over the last 18 months, driven by growth overseas and demand from younger drinkers. An average bottle of Maker’s Mark takes six and half years to produce from start to finish, and since the company doesn’t buy or trade whiskey, it’s been impossible to keep up. 

The first bottle of Maker's Mark, with its signature red wax closure, was produced in 1958.

Beam is the country's second-largest spirits company by volume. It also makes Jim Beam, Sauza tequila and Pinnacle vodka. It's still dwarfed by industry-leading Diageo, the London-based maker of Smirnoff, Tanqueray, Captain Morgan and Johnnie Walker.

It's a tough time to take a risk with one of its oldest and most popular brands. Beam has promised that 25 percent of sales will come from new products, a difficult goal to attain but a critical one for investor confidence.The move met some backlash on social media sites, where some said they would boycott the bourbon if the company went ahead with its plans.

Many also complained that they'd rather see an increase in its price than a decrease in the alcohol. But observers say that by raising the price, Beam would have hurt itself by positioning Maker's Mark to compete against its own higher end brands like Basil Hayden's.

sbomkamp@tribune.com | Twitter: @SamWillTravel

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2 persons of interest questioned in Hadiya Pendleton's death

Police are questioning two persons of interest in the slaying of 15-year-old Hadiya Pendleton, a day after first lady Michelle Obama attended the funeral for the teen whose death has become a symbol of escalating violence in Chicago, according to police sources.

The two men, 19 and 20, were pulled over around 67th Street and South Chicago Avenue early this morning after detectives heavily canvassed the area of Harsh Park and tracked down witnesses to the shooting Jan. 29, the sources said. No charges have been filed.

Hadiya was fatally shot in the park about a mile north of President Barack Obama's Kenwood home, a little more than a week after the honor student performed with the King College Prep band in Washington during inauguration festivities. Two other teens were wounded.

Mayor Rahm Emanuel personally called Hadiya's parents, Cleopatra Cowley-Pendleton and Nathanial Pendleton, to inform them of the developement, according to a source.

A relative of Hadiya said the development is a "good response" and better information than the family had Saturday. 

Arrests and charges "will bring a small level of closure to the family, although (the shooter) still will be allowed to eat, drink, mingle," said Shatira Wilks, a cousin and family spokesperson. "The thing about that is, Hadiya is no longer to do so."

On how Hadiya’s family is doing, Wilks said, "Everyone keeps asking that. I don’t know if you’ll ever get an answer that we’re feeling good or we’re feeling fine."

Hadiya's death occurred during the deadliest January for Chicago in a decade, and it came on the heels of a homicide total last year that was the highest since 2008.

The first lady's attendance at Hadiya's funeral placed Chicago even further into the spotlight of a national debate over gun violence that has polarized Congress and forced the president to take his gun control initiatives on the road to garner more public support.

Neither the first lady nor elected officials gave remarks during the funeral. Only the friends and relatives who knew Hadiya best were allowed to speak.

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For Families Struggling with Mental Illness, Carolyn Wolf Is a Guide in the Darkness

When a life starts to unravel, where do you turn for help?

Melissa Klump began to slip in the eighth grade. She couldn’t focus in class, and in a moment of despair she swallowed 60 ibuprofen tablets. She was smart, pretty and ill: depression, attention deficit disorder, obsessive-compulsive disorder, either bipolar disorder or borderline personality disorder.

In her 20s, after a more serious suicide attempt, her parents sent her to a residential psychiatric treatment center, and from there to another. It was the treatment of last resort. When she was discharged from the second center last August after slapping another resident, her mother, Elisa Klump, was beside herself.

“I was banging my head against the wall,” the mother said. “What do I do next?” She frantically called support groups, therapy programs, suicide prevention lines, anybody, running down a list of names in a directory of mental health resources. “Finally,” she said, “somebody told me, ‘The person you need to talk to is Carolyn Wolf.’ ”

That call, she said, changed her life and her daughter’s. “Carolyn has given me hope,” she said. “I didn’t know there were people like her out there.”

Carolyn Reinach Wolf is not a psychiatrist or a mental health professional, but a lawyer who has carved out what she says is a unique niche, working with families like the Klumps.

One in 17 American adults suffers from a severe mental illness, and the systems into which they are plunged — hospitals, insurance companies, courts, social services — can be fragmented and overwhelming for families to manage. The recent shootings in Newtown, Conn., and Aurora, Colo., have brought attention to the need for intervention to prevent such extreme acts of violence, which are rare. But for the great majority of families watching their loved ones suffer, and often suffering themselves, the struggle can be boundless, with little guidance along the way.

“If you Google ‘mental health lawyer,’ ” said Ms. Wolf, a partner with Abrams & Fensterman, “I’m kinda the only game in town.”

On a recent afternoon, she described in her Midtown office the range of her practice.

“We have been known to pull people out of crack dens,” she said. “I have chased people around hotels all over the city with the N.Y.P.D. and my team to get them to a hospital. I had a case years ago where the person was on his way back from Europe, and the family was very concerned that he was symptomatic. I had security people meet him at J.F.K.”

Many lawyers work with mentally ill people or their families, but Ron Honberg, the national director of policy and legal affairs for the National Alliance on Mental Illness, said he did not know of another lawyer who did what Ms. Wolf does: providing families with a team of psychiatrists, social workers, case managers, life coaches, security guards and others, and then coordinating their services. It can be a lifeline — for people who can afford it, Mr. Honberg said. “Otherwise, families have to do this on their own,” he said. “It’s a 24-hour, 7-day-a-week job, and for some families it never ends.”

Many of Ms. Wolf’s clients declined to be interviewed for this article, but the few who spoke offered an unusual window on the arcane twists and turns of the mental health care system, even for families with money. Their stories illustrate how fraught and sometimes blind such a journey can be.

One rainy morning last month, Lance Sheena, 29, sat with his mother in the spacious family room of her Long Island home. Mr. Sheena was puffy-eyed and sporadically inattentive; the previous night, at the group home where he has been living since late last summer, another resident had been screaming incoherently and was taken away by the police. His mother, Susan Sheena, eased delicately into the family story.

“I don’t talk to a lot of people because they don’t get it,” Ms. Sheena said. “They mean well, but they don’t get it unless they’ve been through a similar experience. And anytime something comes up, like the shooting in Newtown, right away it goes to the mentally ill. And you think, maybe we shouldn’t be so public about this, because people are going to be afraid of us and Lance. It’s a big concern.”

Her son cut her off. “Are you comparing me to the guy that shot those people?”

“No, I’m saying that anytime there’s a shooting, like in Aurora, that’s when these things come out in the news.”

“Did you really just compare me to that guy?”

“No, I didn’t compare you.”

“Then what did you say?”

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The fine line between legitimate businesses and pyramid schemes

Controversy is again casting a shadow over the multilevel marketing industry, as nutritional supplement company Herbalife Inc., which has thousands of distributors in the Chicago region, has been publicly called a pyramid scheme by a prominent investor — an allegation the company vigorously denies.

Meanwhile, a different multilevel marketer, Fortune Hi-Tech Marketing, was shut down in recent weeks after a lawsuit was brought by regulators and several states, including Illinois, alleging the company scammed consumers out of $169 million. The scheme affected an estimated 100,000 Americans, including some in Chicago, where it targeted Spanish-speaking consumers, the Federal Trade Commission alleged.

Most people outside the industry might have only a vague notion about multilevel marketing, also called network marketing and direct selling. It often involves personal sales of cosmetics, wellness products or home decor items — or as critics flippantly call it, "pills, potions and lotions" — usually sold through product parties hosted by friends or relatives.

For sellers, the companies offer the appeal of starting a business on the cheap with little training, working from home and being their own boss, if only for part-time money. Some might recruit friends and family to become sellers, which augments their own commissions and gives them a shot at the six-figure compensation many such marketing companies tout but few distributors attain.

The largest multilevel marketing companies, often known as MLMs, are household names: Avon, Mary Kay, Pampered Chef and Amway. MLMs have annual sales of about $30 billion, with about 16 million people in the United States selling their products, according to the industry group Direct Selling Association, which represents these firms and others.

The recent controversies might raise the question: What's the difference between a legitimate multilevel marketing company and an illegal pyramid scheme, in which only people who get in first — at the top of the pyramid-like structure — make money and everyone else is a dupe?

The harshest critics maintain there is no difference, that there's no such thing as a legitimate MLM and that the industry's secrets stay safe because of a cultlike mentality and a blind eye of regulators.

Jon M. Taylor, who was once a seller for an MLM company, said he has studied the industry for 18 years and analyzed more than 500 MLM companies. He maintains the website MLM-thetruth.com and offers a free e-book there.

"I have not yet found a good MLM — a good MLM is an oxymoron," Taylor said.

He said all MLM companies have the same flaw: They depend on endless chains of recruiting new members.  "There is no more unfair and deceptive practice than multilevel marketing," Taylor said.

Tracy Coenen, a forensic accountant and fraud investigator with Sequence Inc. in Chicago and Milwaukee, is author of the Fraud Files Blog. She is also a critic.

"Multilevel marketing companies are pyramid schemes that the government allows to operate," said Coenen. "The only difference is that Herbalife, or any multilevel marketing company, has a tangible product that they use to make their pyramid appear legitimate."

The Direct Selling Association says MLMs are legitimate businesses, and that the group has about 200 members carefully screened by the organization to ensure they are not pyramid schemes and don't use deceptive practices.

The Federal Trade Commission agrees there are legitimate MLMs. The difference between a legitimate business and pyramid scheme comes down to products.

If the company and its distributors make money primarily from the sale of products to end-users (and not boxes of product accumulating in a distributor's garage), it's OK.

By contrast, a pyramid scheme compensates those at the top of the pyramid with participation fees paid by those recruited at the bottom. It eventually collapses when the scheme can't recruit more people.

But identifying a pyramid scheme can be difficult because MLMs typically have product sales, along with recruitment fees and recruitment incentives.

"It gets cloudy when you have a situation where you have fees being paid for both," said Monica Vaca, assistant director of the FTC's division of marketing practices. "It's very nuanced."

While prosecuting an MLM can seem somewhat of a judgment call, cases have a common factor: deceptive promises about how much money distributors will earn, Vaca said.

In the Fortune Hi-Tech Marketing case filed last month, C. Steven Baker, director of the FTC's Midwest region, said, "These defendants were promising people that if they worked hard they could make lots of money. But it was a rigged game, and the vast majority of people lost money."

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