Did Researchers Just Discover the Cause of Pancreatic Cancer?

By Sean Williams | More Articles 
January 31, 2015 | Comments (10)

Source: Flickr user Sunil Joshi.

Although no cancer diagnosis is welcome, perhaps no cancer type comes with a more frightening outlook than pancreatic cancer.

According to data from the American Cancer Society, pancreatic cancer is the twelfth most commonly diagnosed type of cancer. In 2014 alone, an estimated 46,420 cases were newly diagnosed. But what's truly disconcerting is that pancreatic cancer is the fourth-leading cause of cancer-related death, behind only lung, colon, and breast cancer, which are far more prevalent on the basis of diagnosis.

Further evidence of the tough battle being fought against pancreatic cancer is observed in the five-year survival rates presented by ACS. Combining all stages of pancreatic cancer, the five-year survival rate is a mere 6%, the lowest of all of the major cancer types. Metastasized pancreatic cancer results in a five-year survival rate of just 2% compared to localized pancreatic cancer, where five-year survival rates are a better, but still disappointing, 24%. 

To say that pancreatic cancer needs targeted therapies as soon as possible would be a vast understatement. However, finding those therapies begins with better understanding the mechanism by which pancreatic cancer begins. The good news is that significant progress may have just been made on this front.

Researchers make major headway on pancreatic cancerAccording to research conducted by the University of Utah Health Sciences and published in the most recent edition of eLife, researchers may have identified the method by which pancreatic cancer forms.

Source: Merck KGaA.

University of Utah researchers combed through previously published study data and discovered a receptor for sphinogosine 1-phosphate, or S1P2, that's critical for a process known as extrusion. Extrusion is where cells are squeezed out of overcrowded tissue to die. When the researchers focused on pancreatic cancer, they observed that a reduction in S1P2 levels led to reduced extrusion -- and as you might have surmised, reduced extrusion led to the formation of masses.

One the most interesting findings of the study was that not only did reduced S1P2 levels result in mass formation about half of the time, but it also led to cells being extruded underneath overcrowded tissue layers rather than on the outside of overcrowded tissue. It was proposed by the researchers that this could be the mechanism by which pancreatic cancer becomes invasive.

Source: National Cancer Institute via Wikimedia Commons.

Also, researchers tested whether or not defective extrusion could be "bypassed" with the addition of focal adhesion kinase inhibitors, or FAK inhibitors. FAK inhibitors control extrusion cell death under normal circumstances. To the amazement of researchers, adding FAK inhibitors returned cell death to normal, signaling that FAK inhibitors should be explored further as a therapy to slow or halt pancreatic cancer cell progression as well as in other forms of solid tumors such as lung cancer.

Obviously, more testing needs to be conducted on FAK inhibitors and the factors that ultimately contribute to pancreatic cancer, but the University of Utah's findings are a substantial leap forward that could help researchers hone in on new therapies designed to fight pancreatic cancer.

Innovative therapies may be on their wayIf we can find a silver lining in what's otherwise an unfortunate diagnosis, it's that a number of new pathways are currently being explored by drug developers to treat pancreatic cancer.

Among FAK inhibitors, the one to watch is Verastem's (NASDAQ: VSTM  ) VS-6063, known also as defactinib. This drug was acquired from Pfizer in 2012 and has been shown in a number of phase 1 studies to be safe. Later-stage studies will dig into whether or not the drug is truly effective. While it's currently being directed at lung and ovarian cancer, as well as mesothelioma, it's not out of the question that Verastem will expand its study of VS-6063 to include pancreatic cancer in the future, especially following the University of Utah's encouraging findings.

Three other unique pathways to fighting pancreatic cancer that could yield positive results include hypoxia-targeted drugs, cancer immunotherapies, and cancer stem cell-focused drugs.

Threshold Pharmaceuticals (NASDAQ: THLD  )  and its partner Merck KGaA (not to be confused with the other Merck) are currently developing TH-302, a drug that targets hypoxic cells, or cells exhibiting low levels of oxygen. Why hypoxia? Cancer cell growth is often without rhyme or reason, and tumors can occasionally grow faster than blood vessels. Long story short, select areas of a tumor can be left starving for oxygen -- a condition that would be very uncommon in normal tissue. Thus, TH-302 targeting these hypoxic regions should result in targeted cancer cell death while harming few, if any, healthy cells.

TH-302 is currently being studied in a pivotal phase 3 trial known as MAESTRO, which hit its enrollment target this past November. Data from this study is expected in the first quarter of 2016.  

A cancer immunotherapy works by utilizing a patient's immune system and enhancing it to recognize cancer cells that would otherwise go undetected.

Source: NewLink Genetics.

NewLink Genetics (NASDAQ: NLNK  ) is currently running two late-stage studies for pancreatic cancer (IMPRESS and PILLAR) utilizing Algenpantucel-L. The idea for NewLink is to get cancer cells to express alpha-gal, a carbohydrate that the body has built up a natural immunity to. The alpha-gal acts as a beacon for the body's immune system so it can seek out and destroy cancer cells. Last year, NewLink announced that its Algenpantucel-L therapy led to durable complete responses in three patients ranging from 12 to 36 months, which is exceptionally encouraging considering pancreatic cancer's poor five-year survival rates.

Finally, OncoMed Pharmaceuticals (NASDAQ: OMED  ) , in collaboration with Celgene(NASDAQ: CELG  ) , is developing a drug known as tarextumab (previously OMP-59R5), which targets cancer stem cells. Just as our normal stem cells differentiate into a number of other cell types during our lifetime, cancer stem cells are believed to be the source of metastasis and cancer recurrence. Thus, eliminating cancer stem cells could reduce or eliminate the risk of a cancer relapse or metastasis.

In the phase 1b ALPINE study, which examined 40 patients as a front-line metastatic pancreatic cancer treatment, tarextumab in combination with Celgene's Abraxane (an FDA-approved pancreatic cancer treatment) led to median overall survival of 11.6 months, including 14.6 months in certain subgroups of patients that had elevated Notch3 gene expression. Overall, 38% of evaluable patients responded to the drug, with another 35% demonstrating stable disease for a clinical benefit rate of 73%!

A long way to goClearly we still have a long way to go before the pendulum really begins to swing in favor of pancreatic cancer patients. But, we also have more pathways being investigated by drug developers than ever before, especially after the University of Utah's findings regarding the cause of pancreatic cancer. It's my hope that drug developers can make meaningful progress in both research related to the formation of pancreatic cancer, as well as therapies that will deliver substantial improvements in quality of life. A cure certainly isn't out of reach, and every avenue relating to the formation and development of cancer needs to be explored.

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Sean Williams has no position in any stocks mentioned. You can follow him on CAPS under the screen name TMFUltraLong, track every pick he makes under the screen name TrackUltraLong, and check him out on Twitter, where he goes by the handle @TMFUltraLong.

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What Google's Wireless Plans Mean for Verizon, AT&T and You

By Scott Moritz Jan 22, 2015 2:03 PM PT

 

 

Google Inc. (GOOGL)’s plan to become a wireless service provider means stiffer competition for Verizon Communications Inc. (VZ) and AT&T Inc. (T) at a time when price pressure is already shrinking margins in the U.S. mobile-phone industry.

Google wants to offer service directly to consumers and will use Sprint Corp. (S)’s wireless network, according to a person with knowledge of the matter. Google also plans to use T-Mobile’s network, according to technology blog The Information and the Wall Street Journal.

Through the arrangements, Google would become what’s known as mobile virtual network operator, or MVNO. Google would pay for capacity on a carrier’s network and then sell the service to its own customers. The service could be up and running this year, according to another person. When it does start, here are the ripple effects for customers and the entire U.S. mobile-phone industry:

SPRINT, T-MOBILE -- For Sprint and T-Mobile, the arrangement provides extra revenue that can be used to upgrade networks and improve the quality of calls and data. That’s a boon not only for Google’s future customers, but also Sprint’s and T-Mobile’s existing user base.

The deal could add up to as much as $1 billion in earnings before interest, taxes, depreciation and amortization for Sprint and T-Mobile to split in 2018, according to Kevin Smithen, an analyst with Macquarie Securities USA Inc. Sprint may get the lion’s share of that revenue because it has more excess capacity, Smithen wrote in a Jan. 21 research note.

Sprint is especially keen to partner with Google. Masayoshi Son, the president of SoftBank Corp., which bought Sprint in 2013, was integral in facilitating the talks between Sprint and Google, according to a person with knowledge of the matter.

VERIZON, AT&T -- Anything that helps call quality at Sprint and T-Mobile gives those companies extra ammunition for wooing customers from AT&T and Verizon, their larger competitors. Added profit would also give the companies more leeway to undercut AT&T and Verizon on price.

“Like everything else, you have to watch your friends more closely than your enemies, so we will be watching Google closely,” Verizon Chief Financial Officer Fran Shammo said of Google’s reported plans.

Just today, Verizon reported profit that fell short of analysts’ estimates. The culprit? The company has been selling phones and tablets at deep discounts to lure new users and keep existing ones from jumping ship.

Asked whether Google might also partner with Verizon, Shammo said only that the companies have many discussions. He declined to confirm whether the pair had discussed Google reselling Verizon’s wireless service.

GOOGLE -- The company has been mum on its plans. Even so, Google could end up being the biggest winner. It could use MVNO arrangements to market and refine an array of tools, including search, maps and e-mail, delivered via Android, the most popular smartphone operating system globally.

Google, the leader in online search advertising, could also come up with creative ways to tailor mobile marketing messages to its wireless user base.

With a cash hoard of more than $60 billion, Google could also compete aggressively on price.
CONSUMERS -- While Google wouldn’t have direct control over the network and the quality of data and calls sent over it, the company would have a lot of say on they types of phones available and the software and apps users could chose from.

Google is known for clean designs on its search page and Play store. Some of those influences could show up in areas like simpler billing and payment layouts, as well as improvements in customer service.

While Android phones already sync users with various Google apps like books, music, maps, and YouTube, it’s possible the company could offer free streaming TV shows and movies to lure customers. And since Google has a deep understanding of advertising, an ad-subsidized service could also be a possibility.

While Google may want to offer a significant discount, Sprint and T-Mobile may not allow an MVNO to drastically undercut their own prices, according to Macquarie’s Smithen.

Google may aim to rely overwhelming on Wi-Fi signals in order to minimize the traffic over Sprint’s or T-Mobile’s network, according to Craig Moffett, an analyst at MoffettNathanson LLC. Republic Wireless, another MVNO that buys capacity from Sprint, is pushing more than 90 percent of its traffic to Wi-Fi, according to Moffett.

What Google's Wireless Plans Mean for Verizon, AT&T and You

  

Google Inc.’s plan to become a wireless service provider means stiffer competition for Verizon Communications Inc. and AT&T Inc. at a time when price pressure is already shrinking margins in the U.S. mobile-phone industry.

 

Google wants to offer service directly to consumers and will use Sprint Corp.’s wireless network, according to a person with knowledge of the matter. Google also plans to use T- Mobile’s network, according to technology blog The Information and the Wall Street Journal.

 

Through the arrangements, Google would become what’s known as mobile virtual network operator, or MVNO. Google would pay for capacity on a carrier’s network and then sell the service to its own customers. The service could be up and running this year, according to another person. When it does start, here are the ripple effects for customers and the entire U.S. mobile- phone industry:

 

SPRINT, T-MOBILE

For Sprint and T-Mobile, the arrangement provides extra revenue that can be used to upgrade networks and improve the quality of calls and data. That’s a boon not only for Google’s future customers, but also Sprint’s and T-Mobile’s existing user base.

The deal could add up to as much as $1 billion in earnings before interest, taxes, depreciation and amortization for Sprint and T-Mobile to split in 2018, according to Kevin Smithen, an analyst with Macquarie Securities USA Inc. Sprint may get the lion’s share of that revenue because it has more excess capacity, Smithen wrote in a Jan. 21 research note.

 

Sprint is especially keen to partner with Google. Masayoshi Son, the president of SoftBank Corp., which bought Sprint in 2013, was integral in facilitating the talks between Sprint and Google, according to a person with knowledge of the matter.

 

VERIZON, AT&T

Anything that helps call quality at Sprint and T-Mobile gives those companies extra ammunition for wooing customers from AT&T and Verizon, their larger competitors. Added profit would also give the companies more leeway to undercut AT&T and Verizon on price.

“Like everything else, you have to watch your friends more closely than your enemies, so we will be watching Google closely,” Verizon Chief Financial Officer Fran Shammo said of Google’s reported plans.

 

Just today, Verizon reported profit that fell short of analysts’ estimates. The culprit? The company has been selling phones and tablets at deep discounts to lure new users and keep existing ones from jumping ship.

 

Asked whether Google might also partner with Verizon, Shammo said only that the companies have many discussions. He declined to confirm whether the pair had discussed Google reselling Verizon’s wireless service.

 

GOOGLE

The company has been mum on its plans. Even so, Google could end up being the biggest winner. It could use MVNO arrangements to market and refine an array of tools, including search, maps and e-mail, delivered via Android, the most popular smartphone operating system globally.

Google, the leader in online search advertising, could also come up with creative ways to tailor mobile marketing messages to its wireless user base.

 

With a cash hoard of more than $60 billion, Google could also compete aggressively on price.

 

CONSUMERS

While Google wouldn’t have direct control over the network and the quality of data and calls sent over it, the company would have a lot of say on they types of phones available and the software and apps users could chose from.

Google is known for clean designs on its search page and Play store. Some of those influences could show up in areas like simpler billing and payment layouts, as well as improvements in customer service.

 

While Android phones already sync users with various Google apps like books, music, maps, and YouTube, it’s possible the company could offer free streaming TV shows and movies to lure customers. And since Google has a deep understanding of advertising, an ad-subsidized service could also be a possibility.

 

While Google may want to offer a significant discount, Sprint and T-Mobile may not allow an MVNO to drastically undercut their own prices, according to Macquarie’s Smithen.

 

Google may aim to rely overwhelming on Wi-Fi signals in order to minimize the traffic over Sprint’s or T-Mobile’s network, according to Craig Moffett, an analyst at MoffettNathanson LLC. Republic Wireless, another MVNO that buys capacity from Sprint, is pushing more than 90 percent of its traffic to Wi-Fi, according to Moffett.

 

--With assistance from Brian Womack in San Francisco and Olga Kharif in Portland.
To contact the reporter on this story: Scott Moritz in New York at smoritz6@bloomberg.net To contact the editors responsible for this story: Sarah Rabil at srabil@bloomberg.net Tom Giles

 

Dad Arrested for Giving Cannabis Oil to Daughter With Cancer

Beth GreenfieldSenior WriterJanuary 20, 2015

Adam Koessler with Rumer Rose. Photo by Facebook.

The father of a 2-year-old with late-stage cancer is facing jail time for using cannabis oil in an attempt to ease his daughter’s suffering.

When Adam Koessler’s 2-year-old daughter Rumer Rose was diagnosed with stage 4 neuroblastoma recently, he began supplementing her chemo treatments with doses of cannabis oil, seeing “amazing” results. Still, Koessler lives in Australia, where medical marijuana is illegal, and he was arrested Jan. 2 for his efforts; he was released on bail but now faces charges for possessing dangerous drugs and for supplying them to a minor, and is due back in court on Friday. The situation has outraged thousands around the world, who have signed online petitions and raised money in support of the single dad.

STORY: Parents Under Investigation for Neglect After Allowing Kids to Walk to Playground

“He is a father doing whatever possible to save his child… let him go,” writes one of nearly 114,000 supporters on a Change.org petition to drop Koessler’s charges and legalize medical marijuana. Says another, “If the law states that this man cannot give his terminally ill… daughter something that improves her quality of life, than the law needs to be changed. The fact that this man has had his parental rights taken away by an ignorant legal system that has absolutely no right to do so absolutely disgusts me.”

STORY: Infant’s Life Was Saved by Cannabis, Mom Claims

On Christmas Eve, Rumer was diagnosed with stage-4 neuroblastoma — a pediatric cancer that develops from immature nerve cells — according to Koessler, who shared details of his story on a GoFundMe page he set up to help with his daughter’s care. (Koessler could not be reached for comment by Yahoo Parenting.) Doctors proposed 12 months of chemotherapy, while Rumer’s father and mother (who are not a couple), began a complementary therapy of naturopathic medicine, gluten-free meals, and medical-grade cannabis oil, which has been used around the world, with varying success rates, to treat conditions from ulcers and migraines to cancer and epilepsy. While the notion of treating children with marijuana remains controversial, Koessler says the oil worked wonders.

Photo by Facebook

“The results were amazing,” he writes. “What we saw when Rumer was given the medical cannabis oil what nothing short of miraculous. Her cancer ridden little body was alive again — Rumer had almost instant quality of life…Her skin color came back, her eyes were sparkling again…We were certain after seeing these results that her recovery was entirely possible.”

Medicinal marijuana is banned in Australia, though the leader of the state of Victoria, Daniel Andrews, has said he wants to make it legalthere by the end of 2015.

After Koessler’s arrest at a Brisbane hospital, where Rumer is being treated, he was told a condition of his bail was that he could not see his daughter; that was changed on Jan. 16, according to the Brisbane Times. Local supporters are planning a protest for February, while thousands continue to support the family online through Change.org,various Facebook pages, and two GoFundMe pages, for Rumer’s careand for her dad’s legal fees, which have raised more than $15,000 and nearly $4,000 respectively.

On Jan. 9, Rumer was moved to the hospital’s intensive care unit after having seizures. In the meantime, note administrators of Koessler’sFearless Father page on Facebook, “We want to say thank you, to all of the amazing people who are supporting Adam, sending him hundreds of personal messages of support, showing your support on this page. All of that positive is helping Adam to stay calm and believe that good will come of all of this. This is a fight that will make a difference for so many people around Australia and the world.”

Parents Under Investigation for Neglect After Allowing Kids to Walk to Playground

Beth GreenfieldSenior WriterJanuary 15, 2015

Rafi and Dvora Meitiv. Photo by Andrea McCarren/WUSA9

A Maryland family is under investigation for child neglect this week after allowing their kids, ages 6 and 10, to walk together, but without adults, to neighborhood playgrounds.

“The world is actually even safer than when I was a child, and I just want to give them the same freedom and independence that I had — basically an old-fashioned childhood,” mom Danielle Meitiv told theWashington Post. “I think it’s absolutely critical for their development — to learn responsibility, to experience the world, to gain confidence and competency.” Danielle, who grew up in the 1970s in New York City and was allowed to roam freely along with other neighborhood kids, told WUSA9, “The only thing that’s changed between then and now is our fear.”

STORY: Mom Calls Cops on Nanny. Sometimes it Doesn’t ‘Take a Village’ to Raise a Kid.

But officials disagree. In late December, Montgomery County Police picked up the kids, Rafi and Dvora, walking just half a block from home after being alerted by an observer. Six cop cars soon showed up at the family’s house, and the incident spurred Montgomery County Child Protective Services to investigate Danielle and her husband Alexander for child neglect. This week, CPS officials visited the parents at home and also interviewed the children at school — without their parents’ knowledge or consent.

STORY: Parents Greeted by Police After 2-Year-Old Throws Tantrum On Plane

CPS spokesperson Mary Anderson told Yahoo Parenting she could not comment on the specifics of the case, but explained that CPS is bound by law to “follow up on every complaint” it receives, using theMaryland Unattended Children Law for guidance to determine whether a parent “has provided proper care and supervision.” But the law doesn’t address the outdoors, stating that a child under 8 must not be without someone 13 or older while “confined in a dwelling, building, enclosure, or motor vehicle.”

Danielle, a climate-science consultant and fiction writer, and Alexander, a physicist at the National Institutes for Health, could not be reached by Yahoo Parenting. But Danielle recently told Reason via email that she and her husband have been left “frightened and confused” by the situation. She added, “We are good parents, educated professionals, and our children are happy, healthy, well-adjusted, and academically successful. As difficult as it is for us to believe, all of these events occurred as the result of allowing our children to walk along public streets in the middle of the afternoon without our supervision. My husband grew up in the former Soviet Union. Now he wonders if we have to just go along with whatever the authorities want us to do. I keep reminding him that we have RIGHTS in this country and that neither the police nor the bureaucrats can arbitrarily dismiss them.”

The Meitivs consider themselves “free-range parents,” basing some of their parenting philosophy on the book “Free-Range Kids” by Lenore Skenazy (author of the Reason article), Danielle contacted Skenazy for advice and help with publicity in December.

“I agree that sunshine is a great thing when something is going on in the shadows,” Skenazy, whose new reality show “World’s Worst Mom” premiers on Discovery Life on Jan. 22, tells Yahoo Parenting. She has a clear take on the situation — and many others like it, including a Texas mom investigated by child protective services after allowing her 6-year-old to play alone across the street from home in September, a Florida mom arrested for allowing her 7-year-old to walk to the park alone in August, and a South Carolina mom arrested for letting her 9-year-old play alone in a park in July. “We believe our children are in constant danger,” Skenazy says. “Once you believe that, then seeing a child unsupervised for any amount of time…will look like negligence, even when it’s absolutely rational and loving, as it is [with the Meitivs].”

She blames the cultural shift on “a 24-7 media cycle has to appall and scare us” and “a marketplace that’s bent on scaring us,” using major fears like “kidnapping” and “kids not getting into Harvard” to sell parents just about anything.

A much-buzzed-about article in the Atlantic, “The Overprotected Kid,” touched on many of these issues in April, noting, “It’s hard to absorb how much childhood norms have shifted in just one generation. Actions that would have been considered paranoid in the ’70s — walking third-graders to school, forbidding your kid to play ball in the street, going down the slide with your child in your lap — are now routine. In fact, they are the markers of good, responsible parenting.”

Tim Gill, the UK-based author of “Rethinking Childhood,” finds this attitude worrisome. “The basic danger is that by overprotecting children, we leave them less safe — because we deprive them of the very experiences that will build their confidence and help them learn how to deal with everyday challenges as they grow up,” he tells Yahoo Parenting in an email. He agrees with Skenazy that scaremongering is largely to blame (despite crime stats showing that children are safer than they’ve ever been), along with fear of lawsuits and a “zero risk” mindset, or a belief that “it’s our job to protect children at all costs rather than to help them to be resilient.” That belief has a particularly strong hold in the U.S., he says, noting that, in other countries, including Germany and the Netherlands, it’s practically the opposite.

“I’ve been told that in Switzerland,” says Gill, “parents are judged badly if they DON’T let their children walk to kindergarten (yes, kindergarten) on their own.”

How Obamacare Will Impact Your 2014 Taxes

Fiscal Times

Marine Cole 1/20/2015

© REUTERS/Joe Skipper A busy screen is shown on the laptop of a Certified Application Counselor as he attempted to enroll an interested person for Affordable Care Act insurance, known as Obamacare, at the Borinquen Medical Center in Miami, Florida…

The Affordable Care Act is supposed to make health care coverage universal and more affordable to millions of Americans, but it might also make filing your 2014 taxes more cumbersome and more expensive. 

“This tax season is the first time people will experience the financial consequence of the individual mandate, and it will bring additional paperwork and some surprises for taxpayers,” Michael Mahoney, healthcare expert and senior vice present of consumer marketing for GoHealth, a health insurance technology platform, recently told The Fiscal Times in an email.

Related: Get Ready for the Most Miserable Tax Filing Season Ever 

For the vast majority of tax filers, the changes will only mean checking a box to indicate that they had health coverage during 2014. But some of those who signed up for Obamacare will need to take additional steps when filing their taxes this year.

Consumers who signed up for health care through a marketplace will receive a new form this month, called 1095-A, which they’ll have to fill out and will be needed for filing Federal taxes.
On that form, you’ll be asked to figure out whether you received the correct amount of financial assistance, whether you have to be subject to a penalty and whether you can claim an exemption among other things.

Advance Premium Tax Credit

The government has been providing financial assistance to some Americans to lower the monthly cost of health insurance on an advanced basis. These credits have been applied directly to monthly health insurance premiums.

However, since the tax credit is determined based on your estimate of your household income, it needs to be reconciled taking into account your actual household income when you file your tax return. So you may owe money if you’ve underestimated your income, reducing your refund, while it could increase your refund if you’ve overestimated it.

This could impact about 3.4 million, estimated H&R Block, which partnered with GoHealth to help explain to consumers the new overlap with health insurance and taxes.

Related: 3 Reasons to Get a Head Start on Your Taxes

Penalty

If you don’t have health insurance and don’t qualify for an exemption, you’ll have to pay the higher amount between a flat fee penalty and a percentage penalty.

The penalty will be $96 for an adult and $47 for a child for 2014, up to $285 per household, or 1 percent of your annual household income. The penalty will increase in each of the next two years. This could mean a smaller refund or you might owe more in taxes.

“This will be an unpleasant surprise to people who are still unaware that virtually everyone is now required by law to have health insurance,” said Mahoney.

Exemptions

You could lower this penalty or eliminate it if you qualify for one of the exemptions based on financial hardships, religious affiliations and gaps in coverage among others. Just remember that you may need to apply for some exemptions and receive approval.

“Manage your expectations regarding your tax refund, especially if you have received a tax subsidy or were uninsured for three or more months in 2014,” said Mahoney.