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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HSBC to pay record $1.9B fine

British-owned bank HSBC is paying $1.9B to settle a US money-laundering probe. The bank was investigated for involvement in the transfer of funds from Mexican drug cartels and sanctioned nations like Iran. (Dec. 11)

HSBC has agreed to pay a record $1.92 billion fine to settle a multi-year probe by U.S. prosecutors, who accused Europe's biggest bank of failing to enforce rules designed to prevent the laundering of criminal cash.

The U.S. Justice Department on Tuesday charged the bank with failing to maintain an effective program against money laundering and conduct due diligence on certain accounts.

In documents filed in federal court in Brooklyn, it also charged the bank with violating sanctions laws by doing business with Iran, Libya, Sudan, Burma and Cuba.

HSBC Holdings Plc admitted to a breakdown of controls and apologised for its conduct.

"We accept responsibility for our past mistakes. We have said we are profoundly sorry for them, and we do so again. The HSBC of today is a fundamentally different organisation from the one that made those mistakes," said Chief Executive Stuart Gulliver.

"Over the last two years, under new senior leadership, we have been taking concrete steps to put right what went wrong and to participate actively with government authorities in bringing to light and addressing these matters."

The bank agreed to forfeit $1.256 billion and retain a compliance monitor to resolve the charges through a deferred-prosecution agreement.

The settlement offers new information about failures at HSBC to police transactions linked to Mexico, details of which were reported this summer in a sweeping U.S. Senate probe.

The Senate panel alleged that HSBC failed to maintain controls designed to prevent money laundering by drug cartels, terrorists and tax cheats, when acting as a financier to clients routing funds from places including Mexico, Iran and Syria.

The bank was unable to properly monitor $15 billion in bulk cash transactions between mid-2006 and mid-2009, and had inadequate staffing and high turnover in its compliance units, the Senate panel's July report said.

HSBC on Tuesday said it expected to also reach a settlement with British watchdog the Financial Services Authority. The FSA declined to comment.

U.S. and European banks have now agreed to settlements with U.S. regulators totalling some $5 billion in recent years on charges they violated U.S. sanctions and failed to police potentially illicit transactions.

No bank or bank executives, however, have been indicted, as prosecutors have instead used deferred prosecutions - under which criminal charges against a firm are set aside if it agrees to conditions such as paying fines and changing behaviour.

HSBC's settlement also includes agreements or consent orders with the Manhattan district attorney, the Federal Reserve and three U.S. Treasury Department units: the Office of Foreign Assets Control, the Comptroller of the Currency and the Financial Crimes Enforcement Network.

HSBC said it would pay $1.921 billion, continue to cooperate fully with regulatory and law enforcement authorities, and take further action to strengthen its compliance policies and procedures. U.S. prosecutors have agreed to defer or forego prosecution.

The settlement is the third time in a decade that HSBC has been penalized for lax controls and ordered by U.S. authorities to better monitor suspicious transactions. Directives by regulators to improve oversight came in 2003 and again in 2010.

Last month, HSBC told investors it had set aside $1.5 billion to cover fines or penalties stemming from the inquiry and warned that costs could be significantly higher.

Analyst Jim Antos of Mizuho Securities said the settlement costs were "trivial" in terms of the company's book value.

"But in terms of real cash terms, that's a huge fine to pay," said Antos, who rates HSBC a "buy".

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Charges filed in Wrigleyville sports bar stabbing

Police arrested a man at a Wrigleyville bar early Sunday morning after he allegedly stabbed another man in the bar's men's room.

By Rosemary Regina Sobol




Tribune reporter

1:26 p.m. CST, December 10, 2012

A Chicago man appeared in court today after he allegedly jumped out of a bathroom stall at a Wrigleyville bar and stabbed a man in the neck early Sunday morning, police said.

Gregg Greaves, 23, of the 4700 block of North Beacon Street, was charged with aggravated battery causing great bodily harm, police said.

He was ordered held on Monday in lieu of $500,000 bail.

At 12:26 a.m. Sunday, officers were called to the Red Ivy sports bar at 3525 N. Clark St., where the victim told officers Greaves jumped out of a bathroom stall and attacked him with a broken beer bottle, cutting him in the neck, according to a police report.

The victim also suffered cuts on his chin, hands and neck while pushing the assailant away. At some point, another man entered the bathroom and helped hold the attacker until police got there, the report stated.

The victim was taken to Advocate Illinois Masonic Medical Center, where he was treated and released, the report said.

Greaves refused to wear his pants and yelled obscenities while being processed at a police station. Also, while being processed, the man defecated into his hands and threw the matter onto the floor of the station, the report stated.

Outside of court, Greaves defense attorney, Kevin McCubbin, said: "All I've got to tell you is there's two sides to it."

McCubbin said Greaves is originally from Indiana but currently lives in Chicago. Greaves has a degree in industrial engneering and is employed.

McCubbin said his client has never been arrested before. His next date is Dec. 17, officials said.

rsobol@tribune.com

Twitter: @RosemarySobol1

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China party chief stresses reform, censors relax grasp on internet

BEIJING (Reuters) – China must deepen reforms to perfect its market economy and strengthen rule of law, Communist Party chief Xi Jinping said in southern Guangdong, echoing groundbreaking comments by reformist senior leader Deng Xiaoping in the same province 20 years ago.

Xi’s call for reform was reported on Monday, coinciding with an apparent easing of Internet search restrictions that the party has energetically used to suppress information that could threaten one-party rule.

China’s largest microblog service unblocked searches for the names of many top political leaders in a possible sign of looser controls a month after new senior officials were named to head the ruling party.

Searches on the popular Twitter-like Sina Weibo microblog for party chief Xi Jinping, Vice Premier Li Keqiang and other leaders – terms that have long been barred under strict censorship rules – revealed detailed lists of news reports and user comments.

Xi’s comments on the economy came on Sunday during a trip to Guangdong where he paid tribute to Deng, whose visit in 1992 ushered in an era of breakneck economic reform and growth.

“The government earnestly wants to study the issues that are being brought up, and wants to perfect the market economy system … by deepening reform, and resolve the issues by strengthening rule of law,” Xi was quoted by Xinhua state news agency as saying.

Experts say that unless the stability-obsessed party leadership pushes through stalled reforms, the nation risks economic malaise and social woes that could deepen unrest and threaten its grip on power.

It was too early to detect a change of heart on censorship, but Zhan Jiang, a professor at Beijing Foreign Studies University, said the signs were good.

“Things are changing quietly, and it matches what Xi Jinping said before – to achieve progress and change in a steady way,” Zhan said.

Various search terms for Premier Wen Jiabao, who was at the centre of recent New York Times reports that said his family had accumulated massive fortunes during his tenure, were still blocked on Monday.

Chinese social media sites have posed a unique challenge for party leaders whose overarching goal is to maintain political control, while at the same time allowing people to blow off steam.

Analysts have been searching for signs that China’s new leaders might steer a path of political reform. Many expected at least a temporary loosening of censorship rules after the 18th Party Congress.

“Excessively strict control of the Internet will only make things worse,” said Hu Xingdou, a professor at Beijing Institute of Technology. “So we need to allow people to speak and allow them to voice their grievances.”

(Writing by Michael Martina and Terril Yue Jones. Additional reporting by Ben Blanchard, Sally Huang and Sui-Lee Wee; Editing by Nick Macfie)

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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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McDonald's sales rebound in November

McDonald’s took Wall Street by surprise Monday morning, with a November same store sales report that beat expectations and showed particular strength in the U.S. business.

The news follows a weak performance in October that had some investors speculating about the future of the world’s largest restaurant company.

The Oak Brook-based burger giant reported U.S. same store sales up 2.5 percent on the strength of its breakfast business, value offerings, beverages and limited-time offers like the cheddar bacon onion sandwich. In Europe, same store sales grew 1.4 percent, and 0.6 percent in the chain’s Asia/Pacific, Middle East and Africa division.

Overall, same store sales increased 2.4 percent, beating expectations of a roughly flat performance. Company stock rose nearly 1 percent in early morning trading, to $89.35.

"We are strengthening our focus on the global priorities that are most impactful to our customers -- optimizing our menu, modernizing the customer experience and broadening accessibility to our brand to move our business forward," McDonald's CEO Don Thompson said in a statement.

While the sales report is likely to be a boon for the burger giant, investors don’t expect company performance to return to normal levels until early 2013. Winter is typically the slow period for fast food chains, with summer typically being the busiest season.

Baird analyst David Tarantino raised his fourth quarter earnings estimate by a penny Monday morning following the sales announcement. He wrote that while company performance "could remain soft" through the first quarter of 2013, "the November sales report supports our thesis that McDonald's can achieve better performance in 2013 as a whole, with results aided by planned initiatives (including increased emphasis on value plus premium offerings across markets), fewer cost pressures, and less negative currency translation."

The chain has taken a tough stance on slipping U.S. sales. The company’s October sales, which slipped 2.2 percent, marked the first decline in more than nine years. Days later, McDonald’s said U.S. president Jan Fields had resigned and would be replaced by Jeff Stratton.

eyork@tribune.com | Twitter: @emilyyork

MCD data by YCharts

MCD data by YCharts

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3rd quarter: Vikings 14, Bears 7

MINNEAPOLIS -- As snow steadily descended outside the Metrodome on Sunday, the Chicago Bears were reminded that their playoff fate will be determined in the final four games of the regular season.

Although things started poorly Sunday, the Bears fought back. Jay Cutler hit Alshon Jeffery on a 23-yard TD pass just with 1:52 to play before halftime to cut the Vikings' lead to 14-7. The seven-play drive covered 69 yards.

Earlier, after Jeffery fell down on his route, Cutler's pass was intercepted by Vikings cornerback Josh Robinson. He returned the pick 44 yards to the Bears' 5. Adrian Peterson scored his second TD of the day from a yard out to make it 14-0 at the 8:46 mark of the first quarter.

Peterson -- who gained 104 yards in the first quarter -- had greeted the Bears with a 51-yard run on the Vikings' first play from scrimmage down to the Bears' 29. The drive ended with a 1-yard TD run by Peterson with 11:53 left in the first quarter. Blair Walsh converted and the Vikings led 7-0.

More bad news: Robbie Gould suffered a strained calf during warmups, and punter Adam Podlesh had to handle the opening kickoff. Gould was able to kick an extra point in the second quarter.

Bears safety Craig Steltz was ruled out for the game with a chest injury. Defensive tackle Henry Melton left the field on a cart after walking off with an apparent leg injury, but he later returned.

The Vikings represented clear and present danger as the Bears sought to at least cling to a share of the NFC North lead. Upcoming games at home against the Packers and on the road at Arizona and Detroit loomed throughout the December. The Atlanta Falcons own the best record in the conference at 11-1.

The Bears came in with an 8-4 record, having lost three of their previous four games. Injuries to Brian Urlacher, Tim Jennings, Earl Bennett and Lance Louis were among a handful of problems the Bears would attempt to overcome.

The Vikings approached Sunday’s game in desperation mode with a 6-6 record.

The Bears came into the game as the fifth seed in the NFC, having beaten the Vikings 28-10 two weeks ago. A home loss to Seattle last Sunday left the Bears sorely in need of a triumph at the Metrodome. The Bears and Packers entered the day tied with 8-4 records, but Green Bay held the tiebreaker after beating Chicago in Week 2. The Packers host the Lions on Sunday night.

The Bears entered Sunday with a six-game winning streak against Minnesota.

fmitchell@tribune.com

Twitter @kicker34

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U.S. judge names lead plaintiffs in Facebook litigation

NEW YORK (Reuters) – A group of investors including state pension funds in North Carolina and Arkansas will be the lead plaintiffs in securities lawsuits arising out of Facebook Inc’s $ 16 billion initial public offering, a U.S. judge ruled on Thursday.

The investors, in a proposed class-action case, have accused Facebook of misrepresenting its financial condition in the run-up to the May stock offering. They are represented by law firms Bernstein Litowitz Berger & Grossmann and Labaton Sucharow.

The ruling helps set a structure for the Facebook IPO litigation, a headache for the social media company and a nagging reminder of the technical glitches in the highly anticipated stock market debut.

U.S. District Judge Robert Sweet in Manhattan also named lead plaintiffs for lawsuits against NASDAQ OMX Group Inc stemming from the IPO. NASDAQ was sued over allegations that orders to buy and sell Facebook were not properly executed on the first day of trading.

Facebook, which has defended its pre-IPO disclosures, declined to comment on Thursday. A spokesman for NASDAQ declined to comment on the litigation.

Facebook shares made their debut at $ 38 per share, and later fell as much as 50 percent. On Thursday, they closed at $ 26.90, down 2.6 percent.

Sweet consolidated the cases and picked lead plaintiffs to head up most of the 42 lawsuits before him arising out of the IPO.

Under a federal law governing securities lawsuits, courts routinely select a lead plaintiff in class actions. The lead plaintiff typically is the shareholder with the biggest losses, though judges have discretion to pick a different investor.

The plaintiff group picked to lead 31 cases alleging securities violations against Facebook includes the North Carolina Retirement Systems, Arkansas Teacher Retirement System, the Fresno County Employees’ Retirement Association and Banyan Capital Master Fund Ltd.

The group has collectively claimed a combined $ 7.1 million in losses.

“Its members are large, institutional investors with experience representing shareholder classes in similar litigation with the resources to pursue the action,” Sweet said.

In the securities lawsuits against NASDAQ, the judge said First New York Securities LLC, T3 Trading Group LLC, and Avatar Securities LLC would act as co-lead plaintiffs. The group traded a combined $ 316 million in Facebook shares the day of the IPO, the decision said.

The case is In re Facebook, Inc, IPO Securities and Derivative Litigation, U.S. District Court, Southern District of New York, MDL No. 12-2389.

(Reporting by Nate Raymond; Editing by Martha Graybow)

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Cablevision to raise Internet prices by $5 a month

(Reuters) – Cablevision Systems Corp, the New York-based cable operator, said on Thursday it would raise its Internet prices by $ 5 in January, representing an average hike of 3.2 percent for customers’ total monthly bills.

The company said in a statement that prices for its video and phone services will not be affected and that prices for promotional packages, which generally last one year, will not rise.

But all customers who have Internet service as part of their video or phone package will see prices rise.

Cablevision said it had not raised Internet prices in a decade. It raised video prices in 2011, which saw customer bills rise by 2.88 percent on average.

The company said it has invested $ 140 million in improving its Internet network, deployed more than 50,000 WiFi “hotspots,” and puts no usage caps on its service, unlike some cable competitors.

Canaccord Genuity analyst Tom Eagan downgraded his Cablevision rating from “buy” to “hold” on November 27 and said that Cablevision would lose customers if it were to decide to raise prices not long after Superstorm Sandy.

“Given the massive service outages among its subscribers (after Sandy), we don’t believe the company can raise rates … without incurring material customer churn,” Eagan said.

The cable provider, which is controlled by the Dolan family, said in early November that costs from Sandy, which knocked out service for as many as half its customers, would be substantially higher than its $ 16 million bill from Hurricane Irene in 2011.

Like bigger operators Comcast and Time Warner Cable, Cablevision has been losing customers to rivals such as satellite television provider DirecTV and telephone operator Verizon Communications.

Cablevision shares closed up 2.6 percent, at $ 14.16, on Thursday.

(Reporting By Liana B. Baker; Editing by Steve Orlofsky and Leslie Adler)

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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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