News Analysis: A Debate on Coated Aspirins and Aspirin Resistance

Millions of Americans take low-dose aspirin every day to prevent heart attacks and strokes. But a study published last week challenges some cherished beliefs about the familiar remedy, leaving some consumers to wonder if they should throw out their coated pills and others concerned that they unnecessarily may be taking expensive substitutes.

The study, published in the journal Circulation, by researchers at the University of Pennsylvania, tested 400 healthy people for evidence that aspirin did not work in them, a phenomenon called “aspirin resistance.” Aspirin prevents blood platelets from sticking together, which can lead to heart attacks and strokes. Previous studies have estimated that anywhere from 5 to 40 percent of the population is resistant to aspirin’s effects.

But the study essentially found that the condition doesn’t exist: they could not document a single case of true aspirin resistance in their sample. What had appeared to be aspirin resistance, they said, actually was caused by the coating commonly used on aspirin pills intended to protect the stomach. The coating slowed the drug’s absorption into the body.

The study didn’t evaluate whether coated aspirin was less likely to prevent heart attacks or strokes, said Dr. Garret FitzGerald, one of the authors. And people who took the coated aspirin in his study eventually showed a response to it.

But people who seek out coated aspirin may be doing so unnecessarily, he said, especially since previous studies have not consistently shown that the coating even prevents gastric problems.

“There’s no rationale for you to be on coated aspirin,” said Dr. FitzGerald, who is a cardiologist and chairman of pharmacology at the University of Pennsylvania.

Some cardiologists have begun advising patients to seek out uncoated aspirin because other studies have suggested that the uncoated type may be more effective. But finding it isn’t so easy. Even cheaper store brands, like those sold by CVS and Wal-Mart, come with a so-called enteric coating. One of the few uncoated aspirins on the market is St. Joseph’s chewable variety — the old orange-flavored baby aspirin.

But other experts, like Dr. Steven E. Nissen, a cardiologist at the Cleveland Clinic, see no real harm in taking coated aspirin, which is cheap and readily available. Many major studies of aspirin have been conducted using the coated variety.

The new study also calls into question the very idea of aspirin resistance. Testing for the condition became more widespread in the early 2000s, as expensive prescription alternatives like the blood thinner Plavix (also called clopidogrel) gained popularity. Many cardiologists suspected that the timing was not a coincidence.

“Before clopidogrel, we had never heard of aspirin resistance,” said Dr. Sanjay Kaul, a cardiologist at Cedars-Sinai Medical Center in Los Angeles. “It seemed to be that this was driven mostly by marketing considerations.” The new study raises the possibility that many patients may have been falsely told that aspirin doesn’t work on them, Dr. Kaul and other experts said.

The University of Pennsylvania study was partially financed by Bayer, the world’s largest manufacturer of branded aspirin, much of which is coated. In a statement, Bayer challenged some of the study’s conclusions and methods, and also said there was evidence that the enteric coating can reduce gastric side effects.

Critics of Dr. FitzGerald’s study also argue that he should have studied aspirin resistance in patients with conditions like heart disease, rather than in healthy people.

But even these critics acknowledge that testing for resistance is probably not worthwhile. Dr. Nissen, who is critical of Dr. FitzGerald’s study, doesn’t test his patients for aspirin resistance. But he said he would be reluctant to switch a patient from another drug back to aspirin now if a test had previously shown they were aspirin-resistant. Changing treatments is always risky, he said.

“If the patient is not bleeding, is not having a complication, am I going to take it away?” Dr. Nissen wondered. “That’s the dilemma we face.”

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Index of California consumer sentiment falls slightly in quarter

Consumer confidence in California fell slightly in the last three months of 2012 but remains near its highest level since the start of the recession, according to a Chapman University index. Above, shoppers visit Rodeo Drive in Beverly Hills.. (Patrick Fallon / Bloomberg)

By Ricardo Lopez

December 11, 2012, 11:29 a.m.

Consumer confidence in California weakened slightly in the fourth quarter of this year, according to a Chapman University index released Tuesday.

The California Composite Index of Consumer Confidence decreased to 92.7 from a revised third-quarter reading of 93.4, which was its highest level since the recession, according to the university.

Despite the latest decline, the index shows consumer confidence has been steadily rising as the labor market has improved.

The index of current economic conditions, a component of the overall index, was 80.6 in the fourth quarter, down nearly four points from a third-quarter reading of 84.2.

The biggest drop was in the index measuring consumers' confidence in future economic conditions, which fell to 98.6 from 105.

That slide probably reflects consumers' worries about the looming "fiscal cliff" -- the year-end federal tax increases and spending cuts scheduled to take effect if Congress does not take action, Chapman economists said. The passage of Proposition 30 in California, which will increase state taxes, also has apparently dampened consumer sentiment.

The index of future spending plans, however, showed a surge in consumers' willingness to spend on big-ticket items such as electronics and appliances.  The index rose 17 points to 105.4 from 88.4.

ALSO:

'Right-to-work' measure passes in Michigan Legislature

'Obamacare,' fiscal cliff leads to small business optimism plunge

Despite ports strike, U.S. cargo volume to rise 3.9% in December

ricardo.lopez2@latimes.com

Follow Ricardo Lopez on Twitter.

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Latin music star Jenni Rivera believed dead in plane crash

Fans of Mexican-American singing star Jenni Rivera held a vigil Sunday night in Lynwood

MEXICO CITY — Mexican American singer Jenni Rivera, the "diva de la banda" whose commanding voice burst through the limits of regional Latin music and made her a cross-border sensation and the queen of a business empire, was believed to have died Sunday when the small jet carrying her and members of her entourage crashed in mountainous terrain.

Rivera, a native of Long Beach, was 43. Mexico's ministry of transportation did not confirm her death outright, but it said that she had been aboard the plane and that no one had survived the crash. Six others, including two pilots, also were on board.

"Everything suggests, with the evidence that's been found, that it was the airplane that the singer Jenni Rivera was traveling in," said Gerardo Ruiz Esparza, Mexico's secretary of communications and transportation. Of the crash site, Ruiz said: "Everything is destroyed. Nothing is recognizable."

Word of the accident ricocheted around the entertainment industry, with performer after performer expressing shock and grief. Fans gathered outside Rivera's four-acre estate in Encino.

"She was the Diana Ross of Mexican music," said Gustavo Lopez, an executive vice president at Universal Music Latin Entertainment, an umbrella group that includes Rivera's label. Lopez called Rivera "larger than life" and said that based on ticket sales, she was by far the top-grossing female artist in Mexico.

"Remember her with your heart the way she was," her father, Don Pedro Rivera, told reporters in Spanish on Sunday evening. "She never looked back. She was a beautiful person with the whole world."

Rivera had performed a concert in Monterrey, Mexico, on Saturday night — her standard fare of knee-buckling power ballads, pop-infused interpretations of traditional banda music and dizzying rhinestone costume changes.

At a news conference after the show, Rivera appeared happy and tranquil, pausing at one point to take a call on her cellphone that turned out to be a wrong number. She fielded questions about struggles in her personal life, including her recent separation from husband Esteban Loaiza, a professional baseball player.

"I can't focus on the negative," she said in Spanish. "Because that will defeat you. That will destroy you.... The number of times I have fallen down is the number of times I have gotten up."

Hours later, shortly after 3 a.m., Rivera is believed to have boarded a Learjet 25, which took off under clear skies. The jet headed south, toward Toluca, west of Mexico City; there, Rivera had been scheduled to tape the television show "La Voz" — Mexico's version of "The Voice" — on which she was a judge.

The plane, built in 1969 and registered to a Las Vegas talent management firm, reached 11,000 feet. But 10 minutes and 62 miles into the flight, air traffic controllers lost contact with its pilots, according to Mexican authorities. The jet crashed outside Iturbide, a remote city that straddles one of the few roads bisecting Mexico's Sierra de Arteaga national park.

Wreckage was scattered across several football fields' worth of terrain. An investigation into the cause of the crash was underway, and attempts to identify the remains of the victims had begun.

Rivera, a mother of five and grandmother of two, was believed to have been traveling with her publicist Arturo Rivera, who was not related to her, as well as with her lawyer, hairstylist and makeup artist; reports of their names were not consistent. Their identities were not confirmed by authorities. The pilots were identified as Miguel Perez and Alejandro Torres.

In the world of regional Latin music — norteño, cumbia and ranchera are among the popular niches — Rivera was practically royalty.

Her father was a noted singer of the Mexican storytelling ballads known as corridos. In the 1980s he launched the record label Cintas Acuario. It began as a swap-meet booth and grew into an influential and taste-making independent outfit, fueling the careers of artists such as the late Chalino Sanchez. Jenni Rivera's four brothers were associated with the music industry; her brother Lupillo, in particular, is a huge star in his own right.

Born on July 2, 1969, Rivera initially showed little inclination to join the family business. She worked for a time in real estate. But after a pregnancy and a divorce, she went to work for her father's record label and found her voice, literally and figuratively.

She released her first studio album in 2003, when she was 34.

Her path had not been easy, but rather than running from it, she wrote it into her music — domestic violence; struggles with weight; raising her children alone, or "sin capitan," without a captain. She was known for marathon live shows that left audiences exhilarated and exhausted; by the fifth hour of one recent performance, she was drinking straight from a tequila bottle and launching into a cover of "I Will Survive."

In a witty and sometimes baffling stew of Spanish and English, she sang about her three husbands, about drug traffickers, in tribute to her father, in tribute to her gynecologist.

She became, in a most unlikely way, a feminist hero among Latin women in Mexico and the United States and a powerful player in a genre of music dominated by men and machismo. Regional Mexican music styles had long been seen as limiting to artists, but Rivera shrugged off the labels and brought traditional-laced music — some of which sounded perilously close to polka — to a massive pop audience.

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'Zero Dark Thirty,' 'Lincoln' make AFI top-10 list

LOS ANGELES (AP) — Kathryn Bigelow's Osama bin Laden thriller "Zero Dark Thirty," Steven Spielberg's Civil War epic "Lincoln" and Christopher Nolan's superhero tale "The Dark Knight Rises" are among the American Film Institute's top-10 movies of the year.

Also on the AFI top-10 announced Monday: Ben Affleck's Iran hostage-crisis drama "Argo;" Benh Zeitlin's low-budget hit "Beasts of the Southern Wild;" Quentin Tarantino's slavery saga "Django Unchained;" Tom Hooper's Victor Hugo musical "Les Miserables;" Ang Lee's shipwreck story "Life of Pi;" Wes Anderson's first-love romance "Moonrise Kingdom;" and David O. Russell's misfit love story "Silver Linings Playbook."

The AFI also picked its top-10 TV shows for the year: "American Horror Story;" ''Breaking Bad;" ''Game Change;" ''Game of Thrones;" ''Girls;" ''Homeland;" ''Louie;" ''Mad Men;" ''Modern Family;" and "The Walking Dead."

Creative ensembles for the films and TV shows will be honored at a luncheon in Los Angeles on Jan. 11.

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Online:

http://www.afi.com

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A Breakthrough Against Leukemia Using Altered T-Cells

PHILIPSBURG, Pa. — Emma Whitehead has been bounding around the house lately, practicing somersaults and rugby-style tumbles that make her parents wince.

It is hard to believe, but last spring Emma, then 6, was near death from leukemia. She had relapsed twice after chemotherapy, and doctors had run out of options.

Desperate to save her, her parents sought an experimental treatment at the Children’s Hospital of Philadelphia, one that had never before been tried in a child, or in anyone with the type of leukemia Emma had. The experiment, in April, used a disabled form of the virus that causes AIDS to reprogram Emma’s immune system genetically to kill cancer cells.

The treatment very nearly killed her. But she emerged from it cancer-free, and about seven months later is still in complete remission. She is the first child and one of the first humans ever in whom new techniques have achieved a long-sought goal — giving a patient’s own immune system the lasting ability to fight cancer.

Emma had been ill with acute lymphoblastic leukemia since 2010, when she was 5, said her parents, Kari and Tom. She is their only child.

She is among just a dozen patients with advanced leukemia to have received the experimental treatment, which was developed at the University of Pennsylvania. Similar approaches are also being tried at other centers, including the National Cancer Institute and Memorial Sloan-Kettering Cancer Center in New York.

“Our goal is to have a cure, but we can’t say that word,” said Dr. Carl June, who leads the research team at the University of Pennsylvania. He hopes the new treatment will eventually replace bone-marrow transplantation, an even more arduous, risky and expensive procedure that is now the last hope when other treatments fail in leukemia and related diseases.

Three adults with chronic leukemia treated at the University of Pennsylvania have also had complete remissions, with no signs of disease; two of them have been well for more than two years, said Dr. David Porter. Four adults improved but did not have full remissions, and one was treated too recently to evaluate. A child improved and then relapsed. In two adults, the treatment did not work at all. The Pennsylvania researchers were presenting their results on Sunday and Monday in Atlanta at a meeting of the American Society of Hematology.

Despite the mixed results, cancer experts not involved with the research say it has tremendous promise, because even in this early phase of testing it has worked in seemingly hopeless cases. “I think this is a major breakthrough,” said Dr. Ivan Borrello, a cancer expert and associate professor of medicine at the Johns Hopkins University School of Medicine.

Dr. John Wagner, the director of pediatric blood and marrow transplantation at the University of Minnesota, called the Pennsylvania results “phenomenal” and said they were “what we’ve all been working and hoping for but not seeing to this extent.”

A major drug company, Novartis, is betting on the Pennsylvania team and has committed $20 million to building a research center on the university’s campus to bring the treatment to market.

Hervé Hoppenot, the president of Novartis Oncology, called the research “fantastic” and said it had the potential — if the early results held up — to revolutionize the treatment of leukemia and related blood cancers. Researchers say the same approach, reprogramming the patient’s immune system, may also eventually be used against tumors like breast and prostate cancer.

To perform the treatment, doctors remove millions of the patient’s T-cells — a type of white blood cell — and insert new genes that enable the T-cells to kill cancer cells. The technique employs a disabled form of H.I.V. because it is very good at carrying genetic material into T-cells. The new genes program the T-cells to attack B-cells, a normal part of the immune system that turn malignant in leukemia.

The altered T-cells — called chimeric antigen receptor cells — are then dripped back into the patient’s veins, and if all goes well they multiply and start destroying the cancer.

The T-cells home in on a protein called CD-19 that is found on the surface of most B-cells, whether they are healthy or malignant.

A sign that the treatment is working is that the patient becomes terribly ill, with raging fevers and chills — a reaction that oncologists call “shake and bake,” Dr. June said. Its medical name is cytokine-release syndrome, or cytokine storm, referring to the natural chemicals that pour out of cells in the immune system as they are being activated, causing fevers and other symptoms. The storm can also flood the lungs and cause perilous drops in blood pressure — effects that nearly killed Emma.

Steroids sometimes ease the reaction, but they did not help Emma. Her temperature hit 105. She wound up on a ventilator, unconscious and swollen almost beyond recognition, surrounded by friends and family who had come to say goodbye.

But at the 11th hour, a battery of blood tests gave the researchers a clue as to what might help save Emma: her level of one of the cytokines, interleukin-6 or IL-6, had shot up a thousandfold. Doctors had never seen such a spike before and thought it might be what was making her so sick.

Dr. June knew that a drug could lower IL-6 — his daughter takes it for rheumatoid arthritis. It had never been used for a crisis like Emma’s, but there was little to lose. Her oncologist, Dr. Stephan A. Grupp, ordered the drug. The response, he said, was “amazing.”

Within hours, Emma began to stabilize. She woke up a week later, on May 2, the day she turned 7; the intensive-care staff sang “Happy Birthday.”

Since then, the research team has used the same drug, tocilizumab, in several other patients.

In patients with lasting remissions after the treatment, the altered T-cells persist in the bloodstream, though in smaller numbers than when they were fighting the disease. Some patients have had the cells for years.

Dr. Michel Sadelain, who conducts similar studies at the Sloan-Kettering Institute, said: “These T-cells are living drugs. With a pill, you take it, it’s eliminated from your body and you have to take it again.” But T-cells, he said, “could potentially be given only once, maybe only once or twice or three times.”

The Pennsylvania researchers said they were surprised to find any big drug company interested in their work, because a new batch of T-cells must be created for each patient — a far cry from the familiar commercial strategy of developing products like Viagra or cholesterol medicines, in which millions of people take the same drug.

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Holiday retail hiring could break record set 12 years ago

Holiday hiring by retailers is fast approaching a record set 12 years ago, according to a new analysis of government numbers.

So far, retailers have added 619,700 seasonal workers in October and November, 19% more than the 512,600 holiday employees hired over the same period last year, according to consultancy firm Challenger, Gray & Christmas Inc.

If businesses bring on just 140,300 more workers in December, they’ll match the nearly 760,000 employees tacked on to payrolls during the three-month holiday hiring season in 2000 – a record high.

Doing so isn’t a stretch. Last year, retailers hired 147,600 workers in December, bringing the three-month total to 660,200 seasonal employees.

Last month, businesses such as Target and Amazon.com picked up 465,500 additional workers -- a 21% increase from a year ago and slightly above the record set in November 2007. Challenger derives its non-seasonally adjusted data from the Bureau of Labor Statistics.

“Despite all of the uncertainty, all the talk of fiscal cliffs, the widespread damage to retail epicenters on the east coast by Hurricane Sandy, and the continued growth of e-commerce, retailers are hiring holiday workers in record numbers,” said Chief Executive John A. Challenger in a statement.

The influx of workers is being used to staff stores as they expand holiday hours. Chains such as Wal-Mart caused a kerfuffle as they opened even before Black Friday, allowing shoppers in on Thanksgiving. Macy’s stores will stay open for 48 hours straight starting Dec. 21, with 57 stores keeping the lights on for another 24 hours after that.

But whether the hordes of retail associates will be met with crowds of shoppers is unclear. Consumer confidence is at a four-month low. Though Black Friday saw healthy shopping levels, retail sales overall rose a weak 1.6% in November.

ALSO:

Retail sales rise a weak 1.6% in November

Consumer confidence falls sharply amid 'fiscal cliff' worries

Macy's will open doors 48 hours straight before Christmas

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3 killed, 4 wounded in Tulare County shooting

Three people were fatally shot and four others wounded, including two young children, Saturday night on the Tule River Reservation in Tulare County, authorities said.

The suspect, who fled with his two young daughters, was later shot by sheriff’s deputies and taken into custody, according to the Tulare County Sheriff’s Department. The two girls, who were among those shot, were rescued.

The incident began about 7:45 p.m. when the Sheriff’s Department received a 911 call about shots fired in the 100 block of Chimney Road of the Tule River Indian Reservation about 60 miles northeast of Bakersfield, according to a Sheriff’s Department statement.

In a trailer on the property, deputies discovered an adult male and an adult female who had been fatally shot, authorities said. A male juvenile who suffered a gunshot wound was transported to a hospital. 

At a shed on the property, deputies found another male victim who had been fatally shot, authorities said.

The suspect, identified as Hector Celaya, 31, of the Tule River Indian Reservation, fled the scene in a Jeep Cherokee with his two daughters, Alyssa, 8, and Linea, 5, authorities said. An Amber Alert was issued around 11 p.m.

Detectives used Celaya’s cellphone to locate him.

A deputy spotted the vehicle and after failing to make a traffic stop, a slow-speed pursuit began, authorities said.

The suspect eventually stopped and fired his weapon at deputies, who returned fire and struck the suspect twice, seriously wounding him, authorities said.

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'Skyfall,' 'Guardians' duel for box-office win

LOS ANGELES (AP) — James Bond is in a box-office photo finish with Santa Claus and the Easter Bunny over what looks to be the last slow weekend of the holidays.

According to studio estimates Sunday, Sony's Bond tale "Skyfall" took in $11 million to move back to No. 1 in its fifth weekend.

That put it narrowly ahead of Paramount's "Rise of the Guardians," the animated adventure of Santa, the Easter Bunny and other mythological heroes that pulled in $10.5 million.

The two movies inched ahead of Summit Entertainment's "The Twilight Saga: Breaking Dawn — Part 2," which had been tops for three-straight weekends. The "Twilight" finale earned $9.2 million, slipping into a tight race for No. 3 with Disney's "Lincoln," which was close behind with $9.1 million.

The top movies were bunched up so closely that rankings could change once final weekend revenues are released Monday.

The weekend's only new wide release, Gerard Butler's romantic comedy "Playing for Keeps," flopped with $6 million, coming in at No. 6.

"Skyfall" raised its domestic total to $261.6 million and added $20.3 million overseas to bring its international income to $656.6 million. At $918 million worldwide, "Skyfall" has the best cash haul ever for the Bond franchise and surpassed "Spider-Man 3" at $890 million to become Sony's top-grossing hit.

The "Twilight" finale also is a franchise record-breaker, surpassing the $710 million worldwide haul of last year's "Breaking Dawn — Part 1." The finale's domestic total now stands at $268.7 million.

It was another traditionally quiet post-Thanksgiving weekend, with big November releases continuing to dominate in the lull before a pre-Christmas onslaught of movies.

The box office is expected to soar next weekend with the arrival of part one of "The Hobbit," Peter Jackson's "The Lord of the Rings" prelude. After that comes a steady rush of action, comedy and drama through year's end, including Tom Cruise's "Jack Reacher," Quentin Tarantino and Jamie Foxx's "Django Unchained," Seth Rogen's "The Guilt Trip" and Hugh Jackman and Russell Crowe's "Les Miserables."

"The last couple of weeks of the year are some of the strongest every year," said Paul Dergarabedian, an analyst for box-office tracker Hollywood.com. "We are on the cusp of some really huge box office. There's a lot of money still left in the year despite this slow period right now."

Hollywood's domestic revenues have topped $10 billion so far this year, with the industry expected to finish 2012 ahead of the all-time high of $10.6 billion set in 2009.

Trashed savagely by critics, FilmDistrict's "Playing for Keeps" stars Butler as a washed-up soccer star trying to reconnect with his ex-wife (Jessica Biel) and young son. The all-star cast includes Catherine Zeta-Jones and Uma Thurman as soccer moms with the hots for Butler.

In limited release, Bill Murray's Franklin Roosevelt drama "Hyde Park on Hudson" opened solidly with $83,280 in four theaters, averaging a healthy $20,820 a cinema. By comparison, "Playing for Keeps" averaged $2,115 in 2,837 theaters.

Released by Focus Features, "Hyde Park on Hudson" stars Murray as Roosevelt, whose intimate relations with a distant cousin (Laura Linney) become both a source of strength and distraction as the president plays host to the king and queen of England on the eve of World War II.

Estimated ticket sales for Friday through Sunday at U.S. and Canadian theaters, according to Hollywood.com. Where available, latest international numbers are also included. Final domestic figures will be released Monday.

1. "Skyfall," $11 million ($20.3 million).

2. "Rise of the Guardians," $10.5 million ($26 million international).

3. "The Twilight Saga: Breaking Dawn — Part 2," $9.2 million.

4. "Lincoln," $9.1 million.

5. "Life of Pi," $8.3 million.

6. "Playing for Keeps," $6 million.

7. "Wreck-It Ralph," $4.9 million ($5.8 million international).

8. "Red Dawn," $4.3 million.

9. "Flight," $3.1 million.

10. "Killing Them Softly," $2.7 million.

___

Online:

http://www.hollywood.com

http://www.rentrak.com

___

Universal and Focus are owned by NBC Universal, a unit of Comcast Corp.; Sony, Columbia, Sony Screen Gems and Sony Pictures Classics are units of Sony Corp.; Paramount is owned by Viacom Inc.; Disney, Pixar and Marvel are owned by The Walt Disney Co.; Miramax is owned by Filmyard Holdings LLC; 20th Century Fox and Fox Searchlight are owned by News Corp.; Warner Bros. and New Line are units of Time Warner Inc.; MGM is owned by a group of former creditors including Highland Capital, Anchorage Advisors and Carl Icahn; Lionsgate is owned by Lions Gate Entertainment Corp.; IFC is owned by AMC Networks Inc.; Rogue is owned by Relativity Media LLC.

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New Taxes to Take Effect to Fund Health Care Law

WASHINGTON — For more than a year, politicians have been fighting over whether to raise taxes on high-income people. They rarely mention that affluent Americans will soon be hit with new taxes adopted as part of the 2010 health care law.

The new levies, which take effect in January, include an increase in the payroll tax on wages and a tax on investment income, including interest, dividends and capital gains. The Obama administration proposed rules to enforce both last week.

Affluent people are much more likely than low-income people to have health insurance, and now they will, in effect, help pay for coverage for many lower-income families. Among the most affluent fifth of households, those affected will see tax increases averaging $6,000 next year, economists estimate.

To help finance Medicare, employees and employers each now pay a hospital insurance tax equal to 1.45 percent on all wages. Starting in January, the health care law will require workers to pay an additional tax equal to 0.9 percent of any wages over $200,000 for single taxpayers and $250,000 for married couples filing jointly.

The new taxes on wages and investment income are expected to raise $318 billion over 10 years, or about half of all the new revenue collected under the health care law.

Ruth M. Wimer, a tax lawyer at McDermott Will & Emery, said the taxes came with “a shockingly inequitable marriage penalty.” If a single man and a single woman each earn $200,000, she said, neither would owe any additional Medicare payroll tax. But, she said, if they are married, they would owe $1,350. The extra tax is 0.9 percent of their earnings over the $250,000 threshold.

Since the creation of Social Security in the 1930s, payroll taxes have been levied on the wages of each worker as an individual. The new Medicare payroll is different. It will be imposed on the combined earnings of a married couple.

Employers are required to withhold Social Security and Medicare payroll taxes from wages paid to employees. But employers do not necessarily know how much a worker’s spouse earns and may not withhold enough to cover a couple’s Medicare tax liability. Indeed, the new rules say employers may disregard a spouse’s earnings in calculating how much to withhold.

Workers may thus owe more than the amounts withheld by their employers and may have to make up the difference when they file tax returns in April 2014. If they expect to owe additional tax, the government says, they should make estimated tax payments, starting in April 2013, or ask their employers to increase the amount withheld from each paycheck.

In the Affordable Care Act, the new tax on investment income is called an “unearned income Medicare contribution.” However, the law does not provide for the money to be deposited in a specific trust fund. It is added to the government’s general tax revenues and can be used for education, law enforcement, farm subsidies or other purposes.

Donald B. Marron Jr., the director of the Tax Policy Center, a joint venture of the Urban Institute and the Brookings Institution, said the burden of this tax would be borne by the most affluent taxpayers, with about 85 percent of the revenue coming from 1 percent of taxpayers. By contrast, the biggest potential beneficiaries of the law include people with modest incomes who will receive Medicaid coverage or federal subsidies to buy private insurance.

Wealthy people and their tax advisers are already looking for ways to minimize the impact of the investment tax — for example, by selling stocks and bonds this year to avoid the higher tax rates in 2013.

The new 3.8 percent tax applies to the net investment income of certain high-income taxpayers, those with modified adjusted gross incomes above $200,000 for single taxpayers and $250,000 for couples filing jointly.

David J. Kautter, the director of the Kogod Tax Center at American University, offered this example. In 2013, John earns $160,000, and his wife, Jane, earns $200,000. They have some investments, earn $5,000 in dividends and sell some long-held stock for a gain of $40,000, so their investment income is $45,000. They owe 3.8 percent of that amount, or $1,710, in the new investment tax. And they owe $990 in additional payroll tax.

The new tax on unearned income would come on top of other tax increases that might occur automatically next year if President Obama and Congress cannot reach an agreement in talks on the federal deficit and debt. If Congress does nothing, the tax rate on long-term capital gains, now 15 percent, will rise to 20 percent in January. Dividends will be treated as ordinary income and taxed at a maximum rate of 39.6 percent, up from the current 15 percent rate for most dividends.

Under another provision of the health care law, consumers may find it more difficult to obtain a tax break for medical expenses.

Taxpayers now can take an itemized deduction for unreimbursed medical expenses, to the extent that they exceed 7.5 percent of adjusted gross income. The health care law will increase the threshold for most taxpayers to 10 percent next year. The increase is delayed to 2017 for people 65 and older.

In addition, workers face a new $2,500 limit on the amount they can contribute to flexible spending accounts used to pay medical expenses. Such accounts can benefit workers by allowing them to pay out-of-pocket expenses with pretax money.

Taken together, this provision and the change in the medical expense deduction are expected to raise more than $40 billion of revenue over 10 years.

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Leaders and their feeders

A favorite question at entrepreneurship conferences is which world city has the entrepreneurial dynamism to become a major start-up capital on par with Silicon Valley. London, Singapore, Tel Aviv, New York and Berlin are usually cited.

Seldom, however, do you hear anyone propose Boulder, Colo.

That is, unless you are in the company of Brad Feld, an early-stage investor, technology entrepreneur and author of "Startup Communities: Building an Entrepreneurial Ecosystem in Your City," published by Wiley.

Feld is a regular speaker on venture capital investing and entrepreneurship, having founded his first company in 1987. Twitter is not a perfect measure of the quality of a person's opinions, but you do not get 113,000 followers without having a degree of respect from your peer group.

He is a Texan who co-founded his first company in Boston and for 20 years has been proud to call Boulder his home.

To him, this city of just 100,000 people, nestled near Rocky Mountain National Park and a short drive from Denver, is not just the best place to live. He also sees Boulder as an excellent example for those who wish to turn their own town into a start-up community.

"Although I don't have the data to support it, Boulder may have the highest entrepreneurial density in the world," he writes.

Having said that, Feld wants to make clear that all sorts of cities across the world can become home to job-creating new businesses if only they foster the necessary culture.

He sets out a framework for a successful start-up community — that it be led by entrepreneurs with a long-term commitment to the area, that the community be inclusive of anyone who wants to participate and that there be a constant stream of activities that engage all the parties.

Feld differentiates between the entrepreneurial "leaders" of a community and the "feeders," who must support but not try to take charge.

Feeders include government agencies, lawyers, accountants, local universities and angel investors. Problems often occur and areas fail to become start-up communities, he notes, when feeders, rather than the people creating the businesses, try to control the development of an entrepreneurial ecosystem.

This should serve as a warning to Mayor Michael Bloomberg's administration in New York, which is trying to nurture the city's collection of fast-growing Web businesses, nicknamed Silicon Alley.

The book is also an insight into why the U.S. is such an entrepreneurial nation. The generosity of spirit still prevalent in U.S. society shines through Feld's writing. It is a key reason why so many have felt it is where they can achieve their dreams.

"Give before you get" is a mantra repeated several times by Feld. A key message is the power of community, which relies on people committing to their neighborhood for a couple of decades at least.

He also has a short answer for the people who ask how they can create the next Silicon Valley: They can't.

"Trying to create the next Silicon Valley is a fool's errand," he writes. "If that's really your goal, save yourself a lot of heartache and simply move to Silicon Valley."

It is clear from the way he writes about Boulder that Feld has no intention of moving farther west himself any time soon. "I can't imagine a better place to live," he says.

My only criticism is that almost all of his frame of reference is the U.S. His only mention of anywhere else in the world is a brief account of a trip to see some start-ups in Iceland.

But if more people loved and contributed to the places they live, as Feld and others have evidently done in Boulder, we probably would have more start-up communities around the world for him to visit.

Moules is the enterprise correspondent of the Financial Times of London, in which this review first appeared. He is also author of "The Rebel Entrepreneur," published by Kogan Page.

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