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Saturday, June 9, 2018

This could be the end of ObamaCare

ObamaCare could soon be history, thanks to a lawsuit filed by 20 states that claim the Affordable Care Act is no longer constitutional. US Attorney General Jeff Sessions is so sure the states are right that he’s folding his cards. In a rare move, the Justice Department won’t defend a federal law.
The lawsuit argues that last December, when Congress repealed the penalty for not having ObamaCare insurance, it removed the only constitutional grounds for ObamaCare.
Remember that in 2012, the first time the constitutionality of the health law was challenged, Chief Justice John Roberts slyly called the penalty for not having insurance a “tax” and justified a 5-4 ruling in favor of the law by arguing that the US Constitution gives the federal government the power to tax.
Voila, the tax is gone, and with it the flimsy constitutional underpinning of the ObamaCare scheme.
President Trump was on the mark, declaring that “ObamaCare is over” as he signed the tax-reform bill that included repeal of the health care “tax” penalty. At his State of the Union Address, he stated again that “we essentially repealed ObamaCare because we got rid of the individual mandate.”
The media and Democrats ridiculed these statements as typical Trump hyperbole. But Trump’s insight is the central argument being made by the 20 states: Texas and Wisconsin are joined in their lawsuit by Alabama, Arkansas, Arizona, Florida, Georgia, Indiana, Kansas, Louisiana, Maine, Mississippi, Missouri, Nebraska, North Dakota, South Carolina, South Dakota, Tennessee, Utah and West Virginia.
The case is a slam-dunk. Remember that moment on June 28, 2012, when Roberts pulled off one of the biggest bait-and-switches? As the nation listened, he began explaining the court’s ruling on the constitutional challenge to ObamaCare.
He went to great lengths to knock down the Obama administration’s argument that it had the power under the Constitution’s Commerce Clause to compel individuals to buy health insurance and dictate what kind they buy. Roberts spoke for several minutes on how the federal government’s powers are limited and enumerated: “The Commerce Clause is not a general license to regulate an individual from cradle to grave.”
Then suddenly, Roberts shifted, explaining that the court regarded the penalty for not having ObamaCare as a “tax.” The Constitution unambiguously gives Congress the power to tax, and therefore the health law is constitutional. ObamaCare stayed the law of the land.
Roberts finessed the court out of what he likely feared was a dangerous political situation. The justices were being asked to nix President Barack Obama’s signature legislation. Yet allowing a further expansion of the Commerce Clause would have done severe damage, too, eviscerating any pretext that the federal government’s powers are limited. If Congress can make you buy health insurance, how about American cars or US Treasury bills?
But Roberts’ flim-flam ruling couldn’t endure. He built the entire constitutional justification for ObamaCare’s vast takeover of the individual insurance market on a penalty that even ObamaCare’s architects were reluctant to call a “tax.”
Once it was repealed last December, states were bound to challenge the rest of ObamaCare’s insurance regulations, including rules on how to price policies and what must be covered.
Nancy Pelosi claims the challengers are “trying to destroy protections for Americans with pre-existing conditions.” Nonsense.
Pelosi wants to keep the ObamaCare rule that forces healthy people to pay the same premiums as those with serious illnesses. But 5 percent of the population uses 50 percent of the health care. The unfairness is obvious.
States are already fixing this problem — not abandoning the seriously ill but reimbursing insurers for their care out of general revenues rather than trying to foist the cost on other health-insurance buyers.
States are poised to take back the job of regulating health insurance, once the phony justification for ObamaCare is discarded. Proving once again that in politics, as in baseball, it’s not over till it’s over.
Look for more choices and lower premiums in many states — but no loss of coverage, since nearly all the newly insured are on Medicaid, which will be untouched by the court’s ruling.
Betsy McCaughey is a senior fellow at the London Center for Policy Research.
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China is using AI to keep high school students in line


High school students in one Chinese school may want to think twice before dozing off in class. Artificially intelligent cameras with facial recognition tools will be watching.
The Hangzhou No. 11 Middle School has installed a “smart classroom behavior management system,” which captures students’ expressions and movements, analyzing them with big data to make sure they’re paying attention, media reported on Thursday.
The “Big Brother” strategy underscores how AI and facial recognition tools are increasingly being used in China for a host of tasks, from verifying payments and catching criminals to checking the audience at big entertainment events and customers at fast-food joints.
The ubiquitous cameras — part of daily life in most big Chinese cities — are part of an array of surveillance technologies that have raised worries about privacy.
“The system only collects students’ facial expressions and behavior information,” the school’s vice principal, Zhang Guanqun, told news outlet the Paper.
“It can improve interactions between the teachers and students.”
The system will be able to tell if students are reading or listening — or napping at their desks. It can detect expressions like happiness, repulsion, fear, anger and befuddlement.
Students will get a real-time attentiveness score, which will be shown to their teacher on a screen, media said.
The system is devised by Hikvision Digital Technology, one of the world’s biggest suppliers of security cameras and which is developing its own AI technology.

Pervasive surveillance has long been used in China to deter crime, but many fear that authorities are trying to create a surveillance state, both online and off, to keep track of citizens and crack down on dissent.
The extensive use of cameras has sparked some controversy.
Chinese cyber security firm Qihoo 360 shut down a livestreaming platform last year that allowed people to stream footage from surveillance cameras in locations such as classrooms, restaurants and grocery stores.
The Hangzhou school vice principal said that after a month-long trial, students had begun to accept the monitoring and had improved their behavior.
But some people have been dismayed.
“Is this a concentration camp? They are kids, not the target of dictatorship,” wrote one person on the Weibo social media platform.
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Hydrogel could enable pancreatic islet transplants for diabetes


Scientists searching for Type 1 diabetes cures have long been interested in transplanting functioning pancreatic islet cells into patients, but the danger of immune system rejection has been an obstacle. A team from from Georgia Tech, the University of Louisville and the University of Michigan, however, transplanted islets into mouse models of diabetes, along with a hydrogel that trains immune cells to accept the transplants.
The combination staved off rejection in the mice. If the findings translate to humans, the procedure could treat diabetes without the need for long-term immunosuppressive drugs.
The researchers created polymer hydrogel particles that presented Fas ligand (FasL), a protein that “educates” immune cells known as T-effector cells to accept islets without rejection. They then mixed the hydrogel particles with pancreatic islets before transplantation.
The cells were delivered to the animals’ kidneys and abdominal fat pads. The mice did not reject the graft for at least 200 days. The study appears in the journal Nature Materials.
“We have been able to demonstrate that we can create a biomaterial that interrupts the body’s desire to reject the transplant, while not requiring the recipient to remain on continuous standard immunosuppression,” said Haval Shirwan of the University of Louisville, in a statement. “We anticipate that further study will demonstrate potential use for many transplant types, including bone marrow and solid organs.”

A permanent cure for Type 1 diabetes—one that would eliminate the need for lifelong insulin injections—is in high demand. Stem cell-based therapies have been considered, but they raise the risk of tumors that can develop from residual immature cells. And while donor islet cells have been transplanted in experimental treatments, they almost always fail, even when given along with drugs that suppress immune reactions.
“Drugs that allow the transplantation of the islet cells are toxic to them,” said Andrés García, a professor in Georgia Tech’s George W. Woodruff School of Mechanical Engineering. “Clinical trials with transplantation of islets showed effectiveness, but after a few years, the grafts were rejected. There is a lot of hope for this treatment, but we just can’t get consistent improvement.”
Another problem with islet transplants is that they often lose their blood vessels and do not engraft properly in the patient. García’s lab has shown that it can stimulate blood vessel growth into cells transplanted into the fat pad in mice. In humans, transplants could be delivered into the omentum, a tissue similar to this fat pad.
Other work to improve cell therapies for diabetes include a new culture method that promotes the vascularization of islets created from stem cells and a regenerative approach that involves tapping into a “bank” of pancreatic stem cells that can develop into insulin-producing cells for transplant.
Gene therapy is another potential option: University of Pittsburgh scientists delivered a pair of proteins to the pancreas in mice, “reprogramming” alpha cells into insulin-producing beta cells.
The Georgia Tech scientists and their research partners are now testing their hydrogel-enabled islet transplant approach in nonhuman primates. They believe that if the procedure proves useful in people, it will be relatively easy to scale up and make widely available to patients with diabetes.
“The key technical advance is the ability to make this material that induces immune acceptance that can simply be mixed with the islets and delivered,” Garcia said. “We can make the biomaterial in our lab and ship them to where the transplantation will be done, potentially making it an off-the-shelf therapeutic.”
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Job Strain as Bad as Smoking in Men With Diabetes, Heart Disease


Among men with cardiometabolic disease — diabetes, coronary heart disease, or stroke — those with a demanding job but little control over decisions (job strain) had a higher risk of dying early in a multicohort study.
Moreover, this risk was almost as great as the risk from smoking, even among the men with a healthy lifestyle and well-controlled blood pressure and diabetes.
“The finding that job strain increases mortality risk, even in subgroups of men with cardiometabolic disease but a favorable cardiometabolic risk profile, suggests that standard care targeting conventional risk factors is unlikely to mitigate the mortality risk associated with job strain,” according to lead author Mika Kivimäki, FMedSci, of the University of Helsinki, Finland, and colleagues.
“Other interventions might be needed at least for some patients — possibly including stress management as part of cardiovascular disease rehabilitation, job redesign, or reducing working hours,” Kivimäki said in a statement by his institution.
The study, based on seven European cohort studies from the IPD-Work (Individual-Participant-Data Meta-analysis in Working Populations) consortium, was published online June 5 in Lancet Diabetes & Endocrinology.
Among women with cardiometabolic disease, and men and women without cardiometabolic disease, however, job strain was not associated with an increased risk of dying during a mean 13.9 years of follow-up.
However, the overall findings may have been “biased,” Yulong Lian, PhD, from the Department of Epidemiology and Statistics, College of Public Health, Nantong University, in Jiangsu, China, notes in an accompanying comment,because the study did not include some “important prognostic factors associated with cardiometabolic disease.”
For example, patients with cardiometabolic disease are more likely to have psychological distress, clinical depression, and anxiety, and the researchers did not consider social isolation, loneliness, workplace bullying, or job insecurity in their analysis.
“Nevertheless, their results are provocative and encourage careful attention to work stress reduction among patients with cardiometabolic diseases,” said Lian, adding that the study sheds more light on sex differences in cardiometabolic disease.

Work Stress in Diabetes, Heart Disease

Although guidelines recommend that patients with established cardiometabolic disease should manage work stress, this is based on weak evidence, according to Kivimäki and colleagues.
They identified 102,633 individuals who were enrolled in seven studies in the IPD-Work consortium in Finland, France, Sweden, and the UK from 1985 to 2002 and had replied to questions about job stress.
At enrollment, 3441 participants had cardiometabolic disease, mostly diabetes (78.2%) and less often coronary heart disease (13.6%) or stroke (10.7%).
Those with cardiometabolic disease were a mean age of 48.3 years and 57.4% were men; the other participants were a mean age of 43.8 years and 42.9% were men.
During follow-up, 3841 individuals died.
Among the 1975 men with cardiometabolic disease, those with job strain had a 68% higher risk of dying during follow-up than men without job strain, after adjusting for age, smoking, physical activity, alcohol consumption, body mass index, and socioeconomic status (hazard ratio, 1.68; P = .024).
The increased mortality risk associated with job strain was almost as great as that from current smoking and was greater than the risks from hypertension, high cholesterol, obesity, physical inactivity, and high alcohol consumption (versus not having those risk factors).
Moreover, among men with cardiometabolic disease and a favorable risk profile — that is, they were not obese, physically inactive, smokers, or heavy drinkers, and had normal blood pressure, normal lipids, or both, or high adherence to medications — those with job strain had a two- to six-fold higher risk of premature death than those without job strain.
The authors concluded that more studies are needed “to establish whether systematic screening and management of work stressors, such as job strain, would contribute to improved health outcomes in men with prevalent coronary heart disease, stroke, or diabetes.”
This research “would not only improve understanding of the prognosis” of this disease, “but also inform health policymakers and guideline committees about the need for sex-specific workplace interventions for [its] treatment and management,” added Lian.
The IPD-Work consortium was supported by NordForsk (Nordic Research Programme on Health and Welfare), the UK Medical Research Council, and the Academy of Finland. The authors and editorialist have reported no relevant financial relationships.
Lancet Diabetes Endocrinol. Published online June 5, 2018. Full text, Comment
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Diphtheria-tetanus-pertussis vaccines safe, could be more effective


There were no new or unexpected adverse events, and serious adverse events were rare, following the introduction of diphtheria-tetanus-acellular pertussis (DTaP) vaccines, researchers found.
In a review of a spontaneous surveillance reporting system, about a quarter of patients had injection site erythema, almost 20% had pyrexia and 15% had injection site swelling, reported Pedro L. Moro, MD, of the CDC in Atlanta, and colleagues.
In addition, about 11% of adverse events were serious adverse events, they wrote in Pediatrics.
They noted that postmarketing observational studies for DTaP-containing vaccines have “a good safety record,” but that the initial studies for the DTaP vaccines conducted by the Vaccine Adverse Event Reporting System (VAERS) did not include any of the current DTaP vaccines available, and it only covered a short time period.
Researchers examined data from VAERS from 1991 to reports received by March 17, 2017. Overall, there were just over 50,000 reports that involved receipt of either Infanrix, Pediarix, Kinrix, or Daptacel or Pentacel. The earliest current licensed DTaP vaccines are Infanrix (approved in 1997), and Daptacel (approved in 2002), the authors noted.
About 11% of adverse events were coded as serious; 1.7% reported death. There were 844 deaths reported in total to VAERS, with death certificates and autopsy reports available for 725. Examining causes of death, 48.3% were due to sudden infant death syndrome (SIDS). Of these SIDS cases, 62% occurred in boys and over 90% were age <6 months.
There were 163 reports of anaphylaxis, with median patient age of 4. Of these, symptom onset time could be determined in 103 cases, and about three-quarters of those occurred within 30 minutes post-vaccination. The authors noted that almost 95% of the DTaP vaccines were given at the same time as other routine vaccines, as recommended by the CDC’s Immunization Schedule for Children and Adolescents.
Moro’s group also noted the presence of “vaccination errors” (such as incorrect vaccine or vaccine formulation or administration of the vaccine at the wrong site) in their analysis, and called for “measures to prevent their occurrence.”
In an accompanying editorial, Flor M. Munoz, MD, of Baylor College of Medicine in Houston, noted that after acellular vaccines were introduced, there was a resurgence in pertussis in the U.S., and that the DTaP vaccine has been associated with “a shorter duration of protection,” which requires booster doses in adolescents, adults and pregnant women.
Munoz spoke to the “imperative need” to develop more immunogenic vaccines against pertussis, and spoke to progress being made in the research field.
“Active research is ongoing for the development of novel vaccines, including live attenuated vaccines, whole-cell vaccines with reduced endotoxin content to be less reactogenic, outer membrane vesicles-based vaccines, and acellular vaccine formulations prepared with new adjuvants or additional and novel antigens [as detailed in Vaccine]” she wrote.
The study was supported by the CDC and the FDA.
Moro and co-authors, along with Munoz, disclosed no relevant relationships with industry.
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Is Immunity from MMR Vax Waning?


A 2017 mumps outbreak at a military facility mostly infected service members who had been immunized with the measles, mumps, and rubella (MMR) vaccine, a researcher said here.
Of the six cases of mumps from this outbreak, four of six had IgG titers that were seropositive, indicating they should have been immune to the disease, reported Lindsey Nielsen, PhD, of Brooke Army Medical Center, Fort Sam Houston, in San Antonio, Texas.
Laboratory PCR testing confirmed all six strains were Mumps Genotype G, which could suggest that the current MMR vaccine may not provide cross-protection against this particular strain of the disease, according to the poster presentation at theASM Microbe meeting.
Nielsen noted that many components of the MMR vaccine were developed back in the 1960s — specifically, the mumps component is live attenuated Jeryl-Lynn strain genotype A — but that “the strains circulating are not the strains circulating now.”
“Some of the laboratory tests we do is based on science that is 30 or more years old. We have to make sure that’s still relevant today, taking that into the context of clinical presentation,” she told MedPage Today.
Researchers examined a mumps outbreak that occurred in a barrack of 252 service members. There were 11 service members evaluated for mumps, with six confirmed positive cases. The authors noted that of the 252 service members tested for mumps, 20.1% were mumps IgG seronegative, with seronegativity rates for rubella and measles at 24.4% and 28%, respectively.
They explained that on April 12, three patients reported to the emergency department for evaluation with “fever, swollen unilateral parotitis and malaise.” Two of those three patients had elevated IgM mumps antibodies, which prompted an alert to public health officials and further screening with PCR testing.
On April 20, all 252 service members received a third dose of the MMR vaccine, following the Advisory Committee for Immunization Practices guidelines to give a third dose of vaccine during an outbreak.
But because members of the military are required to provide proof of vaccination and may provide “samples for titer determination” throughout their career, Nielsen and colleagues were able to examine serum samples stored in the Department of Defense Serum Repository to test prior samples of infected patients. There, they found that only two of six confirmed or probable cases had seronegative titers against mumps.
“If we looked at patient records and hadn’t stepped back to think more broadly — that it could be a failure of the test or a lack of cross-reactivity to the vaccine — we would’ve discounted these people,” she said.
Nielsen said that because the third dose of MMR vaccine did “slow the outbreak,” it does argue that perhaps the third dose should be more of a standard rather than being given in response to an outbreak. But she also noted potentially broader issues with the MMR vaccine in general.
“Can [the MMR vaccine] provide cross-protection, how good is that cross-protection, and should we consider whether that is the best avenue for protection?” she said. “Maybe we need to reconsider our vaccination schedule or change the schedule to get more efficacy, or consider reformulation of the current vaccines we have on the market.”
Nielsen and co-authors disclosed no relevant relationships with industry.
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Planning for longer lifespans


For decades, wealth advisors would encourage investors to shift their mix of portfolio assets to more conservative investments as retirement neared.
But no more.
While the final days of an individual’s financial life used to be when they hit their 60s or 70s, today, “that’s kind of the entry point,” says Leslie Voth, president and CEO of Pitcairn, a multi-family office provider.
“A generation ago it would have been unthinkable to have a 90-year-old client still making decisions and still managing the family’s wealth,” Voth says. “Today we have multiple clients where that’s the case.”
People are simply living longer, well into their 80s and 90s. In an upcoming report for clients, Pitcairn points to data indicating “a quarter of 65-year-olds will live past age 90, and one in 10 will live past age 95.”
The problem is wealthy individuals aren’t preparing to live longer. Instead of figuring out how to pay for healthcare or to preserve financial assets to cover day-to-day needs years into the future, they look more narrowly at questions like estate planning and tax efficiency.
Unprepared for Aging
A 2017 survey of high-net-worth and ultra-high-net-worth clients by U.S. Trust found “about half of high-net-worth investors overall don’t feel well-prepared for the financial implications of increasing longevity,” with 70% unprepared for a family member’s “unexpected debilitating or degenerative health issue,” and 67% unprepared for the long-term care of aging parents. Also, 64% said they don’t have the “time or resources to provide care and attention to aging parents.”
For Jim Marion, U.S. Trust’s national fiduciary executive, getting clients to focus on planning for the future has always been “like pulling teeth.” Most of the private wealth manager’s clients “have sufficient assets to sustain themselves regardless of what will happen, both in terms of physical and mental decline,” Marion says. But the “fear of the unknown” has people frozen, he says.
Once people reach their late 50s or early 60s, they are likely to live into their mid-80s or beyond—a “long period of time, but it’s an absolutely manageable period to plan for and model out,” Marion says. “Once you do that the fear of the unknown melts away for people.”
Creating a Family Forum
One of the biggest fears clients have centers on cognitive decline, and the need to put plans in place for managing the family’s investments or the business should the head of a family experience dementia. The Alzheimer’s Association reports that one in three seniors dies with Alzheimer’s or another form of dementia, Pitcairn says, meaning this is a very real scenario for many families.
Pitcairn recently worked with a family who didn’t know what to do when the patriarch, who was in his 90s, continued to make private investments for the family’s partnership, conducting the research on these investments on his own. The patriarch’s children were concerned whether their father was capable of properly evaluating these investments. This upcoming generation formed a committee to study the situation and make recommendations to the senior generation, Voth says.
Getting the senior generation to shift their approach was hard. “It took a few years,” Voth says. “That’s why you need to broach these issues sooner.”
In its upcoming paper, Pitcairn recommends clients create a family forum to discuss potential legal situations well before they happen. Legal documents, such as medical and financial powers of attorney, will create a framework for handling the unexpected. “When it’s time to make difficult decisions, everyone knows where they stand and what role they should play,” the report says.
Given the legal murkiness around what is “competence”—with even doctors disagreeing on a definition—wealthy families would be smart to be clear about what should happen in the case of cognitive decline. The fact that many families have failed to do this kind of planning is already creating a “significant” rise in “litigation and family hostility,” says Patricia Annino, a partner in Rimon’s trust and estate group in Boston. “The question of longevity and competence is, I believe, the issue of the future.’
One way to prepare is by making sure your investments continue to grow by continuing to invest in stocks as well as higher returning, less liquid investments like private equity, according to Pitcairn. A 60-year-old couple today, with 40 more years to live, should have a portfolio invested 55% in global stocks, 15% in hedge funds and private equities, 20% in bonds and 10% in real assets, like real estate. Just 15 years ago, Pitcairn would have recommended a portfolio with fewer international stocks, fewer real assets and more bonds.
As Marion at U.S. Trust points out, for someone who is 70, and who could easily live another 15 or 20 years, staying fully invested in stocks is a reasonable strategy. After all, he says, “you have a couple of market cycles ahead of you.”
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