Speaker is Jason Carlawish, Professor of Medicine and Medical Ethics and Health Policy, Director of Neurodegenerative Diseases, Ethics and Policy Program, and Associate Director of the Penn Memory Center at the University of Pennsylvania, continuing a theme while he did his MD at Northwestern. He trained in internal medicine and geriatrics at Hopkins and the University of Chicago a nice axis. And you get 30 minutes as our keynote for this session. Welcome, Jason. Thanks, Dan. It's great to be here. Thank you. The 26th Annual McLean Conference, it occurred to me, and I thought about that number as a geriatrician, that, Mark, you have just about trained a generation. And that very soon you will have a fellow come who was born when this program started. That is really spectacular. So how are we going to live with Alzheimer's disease? I raised this question because I will posit that I don't think a cure is in the offing. And so we're going to have to learn how to live with the disease. And what I want to talk about are the ethical challenges related to current efforts to answer this question. In particular, I want to address the challenges related to efforts to transform the diagnosis from the category of individuals who are demented as a result of Alzheimer's disease to a continuum defined by various risk markers. And what I'll speak about are both two broad categories of challenges. First, challenges related to conducting the research to arrive at this new world of a dimensional construct. And secondly, I'll speak of the challenges as we arrive at that world and to translate into our daily lives. It's a bit of background. I study this issue around the ethical, legal, and social issues related to cognitive aging. Alzheimer's has been a very useful disease paradigm. I also take care of patients at the Penn Memory Center where I deal with some of the issues I'll be talking about on a weekly basis. The disease of Alzheimer's disease is named after this physician, this gentleman here with the spectacles, Dr. Elias Alzheimer's, who in around 1907 wrote his case of an unusual disease of the cerebral cortex.  And that was his complaint. She was sexually jealous and therefore not doing the duty of a wife.  She was ill. She was demented. And he believed based on his assessment that there was something unusual about her. She wasn't presenting as many of the cases at the asylum were and kept tabs on her. And it's an interesting side note to the story. I mean, we of course know about this story, but one fact which is relatively not spoken about is. He had to leave to go follow his mentor, Emil Kreplin, to another hospital. She of course remained back in the asylum when he first met her and he kept tabs about her. And along, one of his updates he received told him that her husband was tired of paying the cost of her care in the asylum and was going to move her to a lower grade state asylum where it would be cheaper. This of course meant that Alois Alzheimer's would lose track of his unusual case of a disease of the cerebral cortex. He was a neuropathologist as well and he knew what he wanted.  And he then engaged in the classic act of clinical pathologic correlation where he described only a tangle of fibrils indicate the place where a neuron once was previously located. I think this story is interesting as it captures three things about Alzheimer's disease which dominated much of the 20th century. Someone else is complaining about a problem in someone. That someone is disabled and the challenges of taking care of these patients in terms of both social and economic challenges, namely the family was running out of funds to pay for her. And in this case research funds stepped in to keep things going, his own private funds. The other feature of the case of course is it was an act of clinical pathologic correlation, a bedside diagnosis, a sick patient with a history, ultimately tissue was obtained and that history and that tissue were matched up to arrive at the diagnosis. And this graph just kind of depicts the way we understood Alzheimer's disease through much of the 20th century. Simply what I'm describing there is on the x-axis is people are normal until they start to develop signs and symptoms, meeting criteria for dementia, chronic progressive losses and cognition that are disabling, or perhaps an emerging construct of MCI which I'll explain in a minute and over time of course they're getting worse. So this is the disease that I trained in, it's a categorical status based diagnosis that is to say you are ill and that illness based on a history and physical and etc. I believe is most likely explained by the pathology which Alois Alzheimer's described in his case report. The concept of MCI began to be created towards the latter part of the 20th century when studies that captured individuals who had impaired memory, episodic memory performance who then were followed over time, it would begin to show that they were stratifying themselves into being more likely over time to develop dementia, the Alzheimer's type. And so by the late 90s we were beginning to accumulate data that said that you could take an actuarial view of this disease and see forward into its future before it was developing and at the same time that clinical data were being gathered on those people with MCI so too were biological data, imaging scans such as MRI, metabolic imaging such as a PEP scan, spinal fluid samples and the result was this, this is the new vision of of Alzheimer's disease which is emerging now which is this vision not so much of the bedside diagnosis of sick wife bought in by her husband complaining that she's not cooking and doing the wifely duties he expected to a dimensional diagnosis described by a variety of different markers which will signify where you are along the cascade of developing the disease and so in addition to the category of having dementia from Alzheimer's disease on the far right or mild cognitive impairment now has emerged the idea that you could have preclinical Alzheimer's disease now I realize this is a session on clinical ethics but maybe now it's a session on preclinical ethics and and what I've done in this very busy slide that is was created by Cliff Jack at the Mayo Clinic is Dr. Jack began to describe how even before there are the functional losses there is on that blue line the beginning of psychometric changes so you're not functionally impaired but you're not doing as well on cognitive testing as would be expected and even before that we see changes on your MRI in other words your hippocampal region is not as filled with tissue as we would expect and even before that we can see that the physiologic activity of your brain on PET scan and even before that we can measure plaques of amyloid and and and and tangles of tau the things that all of us Alzheimer's observed or the microscope in his postmortem specimen we can observe them with pet imaging of life and so this concept of Alzheimer's disease as this continuum described by these markers has animated the research world at the same time at the very beginning of the 21st century the United States Congress and President Obama did one of their rare bipartisan pieces of legislation of the last six years and past the National Alzheimer's Project Act and the National Alzheimer's Project Act is a federal effort to create a national plan for Alzheimer's disease and it has six goals and one of those six goals is to prevent Alzheimer's disease or cure it by 2025 so the clock is ticking now to do just that so what I want to talk about are the efforts that are underway many of them with taxpayer support and conjunction with industry to do research that is hoped to allow us to achieve the goal of preventing the disease by 2025 this by the way is just an image of that pet imaging just to kind of further give you a little bit of an illustration of it so so on the far right here you see severe Alzheimer's disease meaning all Alzheimer's disease dementia and this is a pet imaging that lights up tau the tangles and you can see here tau pathology and this is someone with mild stage Alzheimer's disease dimension and and this is what's provocative course is that you know someone who has MCI has just a little bit of that pathology now here I've shown you someone who's cognitively normal who has none but of course what the field has discovered is that you can find sorry about that you can find a group of individuals who are cognitively normal but have evidence on pet imaging of tau or amyloid that looks a lot like someone with mild Alzheimer's disease dementia so it's this emerging idea of the preclinical presentation of the disease so what are we investing in right now as a society but we are investing in the trial as what I call an instrument of validation I know we typically think of clinical trials as science studies done to improve the lives of patients show that that a treatment works and that's what all the trials I'm going to tell you about here are designed to do but they're also designed to do another thing which is act as a criterion validation exercise so you take a group of people and you give them an intervention and you measure something about those people and and you give some of the intervention and some you don't give the intervention and and if you see that the people who get the intervention do differently on the thing that you're measuring about them say cognition you can argue that your intervention targeting your biomarker that and link to cognition validates the link between the biomarker and the cognition so for example in the anti-amyloid an asymptomatic Alzheimer's study older adults between the ages of 65 and 80 have a PET scan that measures whether they have elevated amyloid or not they're cognitively normal they would not be diagnosed with Alzheimer's disease dementia they would not be diagnosed with mild cognitive impairment they would be called normal but their PET scan shows elevated amyloid they are being enrolled in a trial where they're assigned to an anti-amyloid drug or a placebo in a blinded fashion followed over three years with cognition measured the goal would be to show that if you can intervene on amyloid and change the rate of decline on cognition now this thing called elevated amyloid in a cognitively normal person becomes the disease of Alzheimer's reified through elevated amyloid linked to this therapy this this drug so that's this concept that's emerged of the theranostic a diagnostic and a therapeutic link together in an individual who's coming to you with no complaints or symptoms so that study is ongoing right now so in that study individuals challenges should we tell them or not the result of their PET scan should they be told that they have elevated amyloid or not elevated amyloid and therefore either are or are not eligible for the clinical trial and I'll talk a bit about that in a moment the second study I have here that is ongoing now is the Diane study or the dominated dominantly inherited Alzheimer's network trial this trial harkens back to August D whose whose brain specimen was found in the in a pathology lab in Germany and she is a carry of one of the dominant mutations that lead to Alzheimer's disease dementia the presinillin mutation and and individuals who carry this dominant mutation if they live long enough generally in about their 40s no more than about their late 50s will develop Alzheimer's disease dementia it's very different than the presentation of Alzheimer's disease typically in the 70s the average age of a patient with Alzheimer's disease in America is about 75 years of age but what these individuals represent is if you will a group who are at heightened risk of developing Alzheimer's disease and so what the dominant inherited Alzheimer's network has done is gathered together across the United States in the world families individuals who have this gene in their family and and enrolled them in a clinical trial to test anti-amaloid agents these individuals are cognitively normal but they have gene so of course the question is is part of the enrollment criteria do you tell them indeed now you do carry this gene so therefore that's why you're eligible for the trial or do you not tell them that and how do you design the study to do that the third study there is the Alzheimer's prevention initiative study they are doing two studies actually one involves individuals with this dominant inherited gene who are residents of the Medellin Columbia region in Columbia where there's a very large cohort of families since about the 18th century who have lived there who carry the presinil and mutation the other study they're doing which I'll focus more on is a study that will enroll individuals who are carriers of two copies of the apoE4 gene the apoE4 gene has been associated with the increased risk of developing late onset Alzheimer's disease the Alzheimer's disease we see in the late 60s or 70s and if you have two copies of that gene you're described as having the highest risk based on a variety of longitudinal cohort studies it's only about 4% of the population carry about two copies of the gene and if you have that carrier that genetic profile your risk of developing Alzheimer's disease depends on the study you look at but it could be as high as 80 or somewhere between about 60 to 80 percent lifetime risk if you live to about 85 years of age so that will be another randomized trial enrolling these people at heightened genetic risk to determine whether we can change the rate of decline in very sophisticated measures of cognition because again like the A4 study like the Diane study these are all cognitively normal individuals and finally the tomorrow trial also uses apoE4 gene as well as another gene that's been discovered to increase risk same design cognitively normal individuals randomized to drug or placebo based on having those genes so I hope the message I'm giving you is a message that harkens back to the early days of cardiovascular disease therapeutics so one of the big breakthroughs in cardiovascular disease therapeutics was gathering together cohorts of individuals who carry dominant genes for familial hyperlipidemia these were individuals who by their thirties had cholesterol plaques on their tendons and by 40 were having heart attacks and strokes and generally the death of cardiovascular disease they were enrolled in a clinical trial to test HMG CoA reductase inhibitors which lowered their cholesterol value decreased the risk of having a heart attack or stroke and therefore established the fact that cholesterol was a was a causal part of the pathway of cardiovascular disease and the rest is of course the story of Lipitor and the rest of us because of course familial hypercluster lemia is quite rare and so these studies particularly the bottom three are very much modeled in that idea of find me a genetically otherwise biomarker heightened risk group of people to help validate the construct of labeling people before they have a heart attack or in the case of Alzheimer's before they're demented again part of this vision of prevention by 2025 where would you like to be well if you talk to the folks in Alzheimer's disease this would might be their vision this is a bus kiosk on 12th and Market Street in my hometown of Philadelphia I don't know if you can read this sign on the side of the bus kiosk but it says know your risk know your a1c hemoglobin a1c or the biomarker measure if you will have diabetic the presence and severity of diabetes the graphic depicts a ambulance that seems to be crashing into a living room because ahead of the ambulance are is I presume it's Hank and his wife and on the side of the ambulance is Hank diabetes complications are coming to get you and so the message here is know your numbers know your a1c because otherwise an ambulance is going to come crashing through your living room and run over you this this this model that has been developed in diabetes and cardiovascular disease is one that the Alzheimer's field lusts after if only we could have our number our measure our biomarker that people would get that would signify now you need your therapeutic in that theranostic model some argue that the likelihood that they'll be just a single number or measures is unlikely and instead probably it'll be something more like this this is the website fracks and this is if you have to pick your country for this but so if you're an American you go to this page you enter your age your gender weight height whether you've had a previous fracture etc. and you click a button and you get your 10-year risk of having a major osteoporotic fracture or hip fracture and then based on that you make your decision about whether or not to treat so what one aspirational goal in the Alzheimer's field is could we get to having this kind of calculator where you would say enter some data like your age your performance on a memory measure your APOE gene and your PET scan for amyloid result and then you would get your risk over time of developing cognitive impairment and that would engender whether or not it's worth you being on and a therapy an anti-amyloid therapy so this the these kinds of actuarial desktop futures of medicine or where the Alzheimer's field wants to be why trust that you've already felt some of the ethical problems of getting there namely how would you do this research I've gestured already to studies that involve measuring amyloid one of the two pathological marks of the disease and normal people and then rolling them in a clinical trial or measuring dominantly inherited genes were non-dominantly inherited genes that increase your risk and the question is is no studies that enroll persons on the basis of having a gene or biomarker associated with Alzheimer's is it ethical to tell the person this result as part of the enrollment criteria or into their research I want to back up and just kind of think about those two broad categories within which we can put Alzheimer's research observational research and interventional research and I think that does I want to depending on your answer to the question I have at the top bullet there really two design options that you have if you don't think that people should know their result then you need to base you need to have designs that use what's called blinded enrollment in other words I'm going to test you because I need to know whether or not you're in my cohort or going to be in my clinical trial but I'm going to do it in a way that's going to keep it hidden from you okay you can do that pretty easily in observational studies you just don't tell people the results in clinical trials what that would require is having an assigned placebo only group so you'd have to take a group of individuals who will test negative you don't tell them that they're negative but you enroll them in the study and they're put in a cohort that gets placebo you don't know that they're in that cohort as the investigator they don't know they're in it they only know as they're getting a blinded study drug and that allows you to not have to tell people oh you're in my study because you had that positive result that's the blinded enrollment approach and and the other approach is transparent where you tell people you have elevated amyloid or you have the APOE4 homozygogene and so therefore you're eligible for my trial so I'd like to sort of make the case that in generally I'm going to argue favors I think favors transparent designs and I'll go through that in a minute the two risks the key issue here around the risks and benefits at stake I think with gene disclosure of genetic information there's obviously the impact on the person of learning that information but there's also issues around consanguous relatives because if I tell you you're an APOE4 homozygote that means that you have consanguous children they are at least an APOE4 heterozygote or you may discover they're actually not your children if they choose to go get tested and they're not an APOE4 heterozygote so that's a very important issue because certainly the people being going in to say the APOE4 homozygote study are older adults with children and they're going to say to them oh you know at Thanksgiving I'm joining this clinical trial and a minute because of I have this gene and so therefore their kids are going to be a finding out that they have a gene there's another issue which I think is the biggest issue and it's why actually we do need to generally disclose which is the psychological harm of disclosure creating the stereotype threat and I'll show you the results of a study that came out American Drill Psychiatry early this year this is a very hard graphic to read given its resolution but the bottom line in a cohort study not a randomized design these investigators disclosed to older adults who are cognitively normal the results of their APOE genotype so they weren't randomized to disclosure so you have the biases of confounding by indication but nonetheless some got the knowledge of their genetic result and then they had a comparison control group who didn't know the APOE result and the take home message from this study as shown here is that those who knew they were an APOE4 carrier rated their memory worse than those who were APOE carriers but didn't know it and those who were APOE carriers and knew it performed worse on measures of memory than those again who were APOE4 carriers and did didn't know it and this is a literature well described in educational psychology of stereotype threat if I tell first described in studies around African Americans and performance on achievement tests if you tell someone is African American this is an achievement test versus the same test given to them and said this is a test of reasoning ability they will do worse on it when it's framed as an achievement test and that's been well described in multiple experimental studies you can do it as well in memory testing with older adults as well if you tell them it's a very hard memory test they'll tend to do worse so the issue that I'm raising here is that if you start telling people their gene or biomarker result you raise the concern of creating a stereotype threat that they'll start to incorporate that into their dare I say mind their sense of their cognition and therefore do worse so okay let's think about analyzing the risks and benefits back to the two broad categories of studies observational studies where the purpose is to inter observe disease in humans versus interventional studies where the purpose is to observe treat humans with a disease in observational studies I would argue you want to simply look at the effect of disease over time and so introducing knowledge of your biomarker and stereotype threat could disrupt measures of disease progression in contrast in interventional study I would argue where it the future of the study is I will now test people and based on their test result I will give them a drug I want to know the compendious effect of not just the intervention but the knowledge of risk marker on outcome of cognition and so there's a argument from scientific value to actually test that effect in addition to testing the effect of the intervention you're giving to people and so it's observational studies I've summed up here it's a bit of a busy table but if you look across issues of scientific validity value favorable risk benefit balance and informed consent I would argue there's a strong argument for blinded designs and observational studies but I think in interventional studies you have a much stronger argument for actually transparent designs tell people they have elevated amyloid tell them they have a double copy of April E4 unless the community of those people who would be recruited make it very clear that they don't want to know that result and there's not a lot of them to recruit from as well in which case you're just not going to be able to fill your study which is what's being done in the dominantly inherited studies however heartbreaking data I've just learned many of the people in the dominant inherited studies are now asking to know what their genotype is because they're tired of the work of being in the study is so arduous in terms of frequent study visits that they'd like to know if it's worth the risks all right we have two studies attached to these clinical trials I'm sort of an observer of them and hang around them the first is the Socrates study the study of knowledge and reactions to amyloid testing people who enroll the study in testing elevated amyloid getting a drug we are interviewing them about three months into drug treatment and then going back a year later and essentially an interviewing a group of non elevated amyloid older adults to better understand the experience of being told you have this particularly with emphasis on the experience of stigma who do they tell what do they tell them and how do people treat you for the April we for study we have two studies that we're going to be running one is to remotely disclose April results because you can't have a genetic counselor everywhere I won't talk more about that but the other is we're going to be testing various interventions designed to reduce stereotype threat to address that very risk I was talking about because of the future of Alzheimer's is this preclinical diagnosis where I label you when you're seemingly well we need to transit that future so that those that label doesn't itself become a harm how bad though it would be enjoyed to a therapy last few points looking forward to this future who will own Alzheimer's all of those tests I told you but especially the imaging tests are owned under the patent laws of America so to the drugs that are being tested and that link of the drug and diagnostic that there are not stick create the opportunity to essentially own Alzheimer's a very fascinating question going forward once you transform Alzheimer's into a preclinical diagnosis on the basis of simple change in a cognitive measure you have the great challenge of how many people treated for how long with a costly therapeutic and diagnostic so Alzheimer's disease in its treatment become an economic problem autonomy becomes an endless trial in this future of Alzheimer's disease where you're at most mildly impaired the need for monitoring if you will about someone's ability to do things because you're sort of now under the surveillance of medicine in your treatment and being followed up on your yearly basis driving laws that require mandatory reporting of diagnoses of Alzheimer's will obviously have to be changed and finally living well in the MCI zone is going to be a real issue if you look at the quality of life measures and people with MCI they're uniformly worse than normal AD dementia people and if we do achieve our goal of prevention we will be living longer in that zone of mildly symptomatic last point at the bad disease this is a patient of mine 91 year old woman lives in assisted living facility many mental of 17 clinical dementia rating of two and this is a drawing she did I know what you're thinking this is this is a bad disease this is like you die twice first in mind and then in body and and you only look at a drawing like this to say how bad it is this little horse that she sketches or whatever she did for activities but actually what this drawing is is a note that she gave to her daughter her daughter wrote me and said this is a map mom made for me one evening when I visited she didn't want me to get lost getting the dining room to meet her at breakfast the big square is the dining room they're the line supposed to show turning left at the elevator again in the hallway the dining room is in the left a short walk down the hall so it's a bad disease we don't want to get it we certainly don't want to die twice and yet I think it's things like this which remind us of the need to help make sense of Alzheimer's and I'll wrap up just please visit this website we've created to do just that help make sense of Alzheimer's I have no more time for questions I do have a question when you compare the study that you presented recently in 2014 to the work by done by Robert Green on the exact issue of disclosing genetic information when we responded with an editorial we thought for the patients that were in the MCI zone it was actually beneficial and we weighed the memory kind of stigma it would present because it is an economic decision when we have a supplement industry that's 33 billion dollars so I can't remember exactly in the 2014 paper did they do a pre and post on the memory capability of those patients or was it simply giving the disclosure of their genetic change pre and post so what was the change over like a bell curve because at the time of the 2010 when Green made the decision it wasn't something that he spursly did he knew perhaps it would bias right so I know you're speaking the reveal study and Robert Green and I have us trial to test just this issue out the bottom line is the reveal study studied 40 to 50 year olds and didn't actually measure cognition so we don't have the ability in the reveal study to know if this bias occurred unfortunately and the MCI study we're doing we also are not measuring cognition so unfortunately the reveal studies don't answer this question about the stereotype threat yeah alright Dan last last question did Jason I like to hear some ideas of how you mitigate the stigma of being diagnosed with MCI yeah so the stigma of disclosure of a biomarker to cartilage normal people right that was what yeah so there is a literature on how to de-bias people to stigma and it involves essentially among other things we're not educating them about the presence of this bias and telling them that this can happen and apparently when you do that intervention you can reduce the effect of of stereotype threat on individuals performing on memory measures for example thanks thank you thank you very much Jason thank you


Hi everybody, Joe for jasperjasecasebreaks.com coming at you with a panini mosaic basketball hobby pack right here 2019-2020 panini mosaic basketball hobby pack random team number 10 With what we've got three different dice rolls right here We got five filler spots that were given away Then we're gonna do the break itself Then we're giving away that mixer spot So pretty exciting big thanks to this group here for getting into it So there are the there are the five spots right here first dice roll Let's roll it randomize it three and a four seven times one two three four five six and seven then final time So top five after seven Brian Gray Brian Frank Christopher Dean and Christopher extra spots for you Which means yes better better odds? To try to win to try to win at those that big mixer spot All right now. Let's gather everyone's names again For the second dice roll where we randomize you a team which I did not fill in and we'll put the results right there Second dice roll of three three and a five eight times one two three four five six seven and Eight I don't think so Tyler. I think we're pretty caught up when I put my breaks away from yesterday we had We had Friday breaks. I didn't even see Friday breaks. So they must be sorted out already Maybe we haven't updated that yet five and three eight times of the teams, but we're on track We're back to our usual fast-shipping ways after a month or so of Being a little bit extra delayed by a couple days, but we're pretty much back on track back to normal All right eight times for the teams Now the United States polls the service though that they may be backed up a little bit So you just have to bear with them especially with the scanning. They're not doing really the point by point-to-point scanning anymore all right No trade windows in this here's just the first half of the list right here, and here's the second half of the list right over here We just want to get to that giveaway part as quickly as possible See what we got here Zach Levine at PJ Washington NBA debut red He's been having a pretty solid season right That's for Charlotte that's gonna go to Matthew Sharap all right now The whole point of this was not this pack It's who's gonna win that $1,400 mixer spot only one winner so 29 sad spots one very happy spot Let's gather everybody's names here It's a worthy chase though. I mean only 50 bucks to try to that's a really great return even if there's only one spot We're giving away All right, so let's gather everybody's names again final third and final dice roll There's a clean list right here. Let's roll it randomize it Wow snake eyes name on top after two very easy left eye of the snake and right eye of the snake and drum roll drum roll drum roll Congrats to well first off very big Apologies to Christopher very close. No cigar unless your name's on top But thanks ever thanks to Chris and thanks everybody for trying I appreciate it But only one winner and that winner is gonna be Sean Maddock Apologies to Chris. I appreciate it not only Chris everybody for taking a risk on this but Sean M Taking the risk and your name's on top after two congrats to you. Thanks everybody We got some more of these to do We still have a couple spots straight up if you don't want to mess around with these fillers So just either way you want to play it whatever your acceptable level of risk is give it a shot on jaskies case breaks calm I'm Joe. I'll see you next time for the next break. Bye. Bye


Hi everyone, Sean with jaspyscasebreaks.com here doing a 2020 Tops Luminaries baseball three box break number 10 random box where we're going to have three box broken three hits in there. We're going to match that up with the three names involved this break and we have Patrick, Patrick and Brandon. So we're going to enter in the hits once we've opened them right here and we're going to use a dice roll to randomize and match up the names and the hits. We're doing this from seven loose boxes we just did break number nine with the three boxes from this the last four remaining were boxes one three four and seven so we're going to go ahead and use those same numbers for the randomizer top three numbers are going to be the three boxes that we use for this break. So here you go one three four and seven Brandon there I don't believe there is a case hit in these I don't think there is like a guaranteed one of one a bat number anything like that without though we've seen any or read at all so dice roll to see which three boxes we're going to be using a two and one three times good luck one two and third and final time so we're doing boxes three one and four seven which was the far this right box is going to be put aside for later so we'll do it in the order that randomizer came up with so box three which is this one box one and box four box number seven that will be for another time good luck everyone let's hope for something crazy so no booklet on this you got a San Francisco giant don't see any giveaways on this one seven out of 15 Buster Posey that's 1086 hit Kings and it's number one and Giants hits total as a catcher certified Hall of Famer there Buster Posey first hit in this break another single this one's an angel and it says outfielder and it's Mike Trout wow look at the patch on that too one two three four color patch Mike Trout three of 15 1297 number two hits total AL West Division 2012 through 2019 he's a pretty good player folks that was a nice patch too and third and final hit guys it's my first Mike Trout auto of it another single card so no booklet this time this one we're going this way let's see what we got blue helmet no logo is that a Dodger hub the Met New York Met Peter Lonzo two out of 15 and it's number two MLB go-ahead home runs in 2019 22 home runs nice so let's go back to the randomizer and enter in all three of those hits this is a nice little grouping here again so we're gonna enter them in exactly the way that they were hit yeah very nice break we've had two back-to-back that were just like okay okay so you see the Mike Po sorry Buster Posey out of 15 Mike Trout out of 15 and the Peter Lonzo out of 15 so let's get a new dice roll actually here let me show you on the list so Buster Posey was the first pull Mike Trout and then Peter Lonzo all out of 15 in this case so let's get a randomizer dice roll here to figure out how many times we're gonna randomize the customers and the hits four and a six ten times so first with the customers Patrick Patrick branded good luck one two three four five six seven eight nine tenth and final time Patrick Patrick Brandon exactly like the orders now ten times on the hits one two three four five six seven eight nine and tenth and final time good luck Mike Trout Buster Posey Peter Lonzo Patrick Cologne Mike Trout patch Otto out of 15 also Buster Posey Otto out of 15 Brandon Tharp Otto out of 15 Peter Lonzo congratulations guys hell of a break there man with some beautiful cards thank you guys for getting in on that my first Mike Trout Otto pull some beautiful cards very cool congratulations guys that was 2020 tops luminaries three box break random box number 10 these were our hits Buster Posey Mike Trout look at the patch on that thing out of 15 how are there 14 more of those out there and then Peter Lonzo on card Otto I'm Sean with jaspyscasebreaks.com check out the store we'll see you guys next time


This is Think Tech Hawaii, Community Matters here. Okay. It's Wednesday. We're doing Community Matters with Tom Yamachika. He is the president of the Tax Foundation of Hawaii, and he helps us understand so many important things about the way our system works and doesn't work in the square building and about the taxes we pay and about the benefits we get. Welcome back to the show, Tom. Thank you for having me on the show, Jake. You wrote a very interesting article in the Civil Beat a few days ago, and it was about a provision in the existing what state constitution requiring a balanced budget. A lot of people, you know, know about that, but the article was interesting because it revealed that that provision doesn't work so well. Can you talk about it? Sure. We have a provision in our state constitution giving what's called an expenditure sealant. And when we have expenditures that are going to exceed the ceiling that are proposed by the governor in his budget, for example, the governor is supposed to, you know, say, oh, we're going to exceed the ceiling by X million dollars, and here's why. And then the legislature's supposed to sign off on it by passing a bill with two-thirds majorities, you know, with the origin, the reasons for it. So I kind of looked at the governor's budget, the supplemental appropriations budget for fiscal year 19, and there's something in the appendix there that says, yes, we are going to exceed the budget, and the reasons for this excess, I'm quoting now, are the substantial costs of social assistance entitlements, support for public education, fringe benefits, and other critical requirements. In other words, government costs money. We know that. We know government costs money. Yeah. Where's the surprise here? Yeah. Where's the surprise? Is there anything unusual in anything that I just mentioned? So why would that be a justification for, you know, busting the budget ceiling? Well, and another question that flows out of that same quote, so to speak, is, wait a minute. It's against the law. In fact, it's against the Constitution not to have a balanced budget. And isn't he saying that he's not going to be able to follow that, that he will in fact not follow that? No, the balanced budget provision is in a different place, and they always balance the budget. Now, when they give the budget to the legislature, it may be out of balance, and I think the last time they gave it to the legislature, it was $200 million short. So then the poor people at the legislature had to make up the difference somehow by nipping here, tucking there, but they had to make a $200 million, and it was not a pretty process. I do feel for the legislators who are caught in the middle trying to get that done, but they had to pass a balanced budget because that's one of our constitutional requirements. So the budget comes up, say, $200 million in excess of a balance, and it goes back to, I guess, the money shares, the money committees financed in the House and what is it ways and means in the Senate, and probably they have to talk about it among themselves between the two, and they have to slice and dice $200 million off what was proposed to them or was last settled on. Not only slice and dice, but there's also revenue enhancement, right, if they can enact new taxes, then that lessens the amount of slicing they have to do. Okay, and that explains the CONAM amendment, trying to raise money for education, does it? No, I don't think it's related. I don't think it's related because they have to pass it within the context of the current session. Right. Okay, it's a timing issue. Yeah. Okay, so I always wondered about this time, how fine a point can you make on the budget? So $200 million is, you know, that's visible like a neon sign at 10 miles away, but you know, what about $1 million or $5 million or $10 million? I mean, how accurately can the legislature actually balance the budget is a moving target, isn't it? Because you don't know exactly what your revenues are going to be, for that matter you don't know exactly what your check writing is going to be, how close can they get? So what they have to do is, the state constitution also provides for a forecasting mechanism called the Consul on Revenues or COR, and what they do is they come up with official revenue estimates, and those are the numbers the legislature has to use by constitution. So okay, they make an estimate. And then what happens is the legislature has to abide by the estimate. If the estimate is wrong, then the budget isn't balanced, am I right? Right. And as time goes on, if they come up with something that balances and then CR changes their numbers, then there's, you know, renewed turmoil at the legislature because they have to balance to the current numbers. So the balance comes out of the Consul on Revenues, it's really balancing against what the Consul on Revenues is telling them is going to be the revenue to the state. Right. I mean that's a little troublesome to me in the sense that it's not an absolute statement at all. It's a statement, it's a requirement that they try and try, meaning that they follow the Consul on Revenues, which could be mistaken. Yeah, but it's better than mere guesswork. Of course.  Just a better guess. And hopefully it's not rife with politics when they make the guess. No, no. And speaking of that, let me tell you about another constitutional privation. And I brought a picture on this one, but let me kind of give you some background first. For a number of years, between 1981 and 2009, we've had a constitutional provision that says, oh, if the state runs up surpluses for a couple of years in a row, then you've got to give some money back to the people. And to accomplish this, we had something called the General Income Tax Credit. So what did they actually do? We've had surpluses. We've had surpluses for, let's say, 20 out of the last 29 years. So 20 out of the 29 years, we were eligible to give some money back to the taxpayer. And can you put up a picture that shows what they actually did? Okay. So see, all those years, there are 29 years. There are nine years where nothing came back, and that's because we didn't have surpluses for two years in a row. For 15 out of the 29 years, what they gave back was a dollar, one dollar. So in a couple of years, they tried giving more substantial monies. What's the height of it? What's the high point there? So I think it was $125 in 1989. And that's for every taxpayer in the state? Yes. In 2007, they also had one, which went up to $160, but it was based on how much you made. So you made more, you got less. Okay. I mean, they made some efforts in some years, but can you explain why those years are so high and the rest of them are at a dollar or less? Well, first year out of the gate in 1981, fresh after the Constitution was minted, they said, well, yeah, I guess we're going to follow this. So they gave us $100 bucks. One year after that, it was, eh, this is kind of crimping our style. Maybe we shouldn't give $100 bucks, but they gave us $20, $100 goes down to $25. And the year after that, well, eh, we really don't want to give that much money back. So we'll drop it to a dollar. What's this kind of? So they are technically in compliance with the Constitution. That they gave something back. They gave something back. But it's got to be tweaked, or it wouldn't be $1 like that. That's got to be the result of a tweak. In other words, it must be something more. And they put something in the bread basket there. Can they do that? They put as much in the bread basket for next time around as they want? Technically, yes, because that's the way the Constitutional provision was written. It didn't say they have to rebate all the money back. They just have to rebate some. And they have them. And they did. They can choose a dollar as some. They did. And then in 2009, of course, what happened is we had a provision that went to the voters and it said, oh, instead of rebating this $1, would you allow us to put some more money in the rainy day fund? And then later on, it was a further amendment. So instead of putting the money in the rainy day fund, can we go make provisions for unfunded liabilities or other things like that? And the voters said yes. So no more general income tax credit after that. So 2009 was the last year. I remember in Linda Lingle's time, she was chasing what I think everybody called the special funds. They were sort of mysterious. And there were funds that money stayed in there for years and years. And it was not clear whether it would ever come out. I mean, does the legislature have that power? I mean, should we do something about this? Where the money could be sort of cockroached in the corner somewhere? I mean, we wouldn't even know about it. And only special members of the government would know about it. There's been a big fight in the legislature every year. There are people like Sylvia Luke, for example, who try to ferret these pots of money out and get rid of them so they can be appropriately anything else. We've also advocated for that in the foundation because that increases transparency. You have money that's socked away somewhere outside of the sunlight. That's not good for transparency. That's not good for a good governance. But agencies love them. Agencies love them. They said, oh, we need to have this program and we need to have a dedicated funding source. Otherwise, you can't be sure that this program will continue to exist. So they've gotten a lot of interest groups that are relying on the agency's mission to buy into that, for example. So if you have Department of Land and Natural Resources, they advocate for special funds for land preservation and taking care of the environment and the environmental groups are all in. You've got to do this. You've got to do this. And then they fight with the money committees who don't want them. So an unending battle. Yeah, interesting. And your chart shows that in recent years, it's been a dollar or zero and there hasn't been any significant return of tax money to the taxpayers. At the same time, my information is the same, is that the money builds up in these funds we didn't even know about. And I guess if I'm a legislator and I want to get rid of money, I'm going to get it off the table, put it away somewhere, so I don't have to return it to the taxpayer, there's lots of ways for me to do that through these special funds. Well, I mean, and you don't even need to do that because there are current needs like unfunded liabilities. Okay, we've been talking a lot about those. We have a problem. We have a problem in that we have promised our state employees all kinds of post-employment benefits. Right? Are we going to have the money to pay those off when these people actually retire? The actuaries are now saying that it's going to take, you know, X million dollars. But that's assuming that the current assets in the retirement system and EUTF will bring in 7% every year, which in current economic conditions is like really unrealistic. And could get more unrealistic. The market's been shaky lately. That is true. And if the actual rate of return is lower, like let's knock it out to maybe 3.5%, then your unfunded liabilities are kind of more like, you know, 35, 40 million dollars with a B. As against our annual budget, which is what, 10 or 12 billion? 14. 14 billion. So you can see that, you know, that 40 billion dollars is huge on the scale of the way we operate here in Hawaii. Right. And so something has got to give. Don't let anybody tell you that there's an excess of money in the state government right now. There really isn't. Well, then maybe it's understandable that they don't give any money back and they hold it for a rainy day because we all know there's going to be a rainy day. Maybe it's a good idea. Yeah. What's been happening recently is around June 30th, July 1st or something like that. Somebody from the governor's office or budget and finance goes on and says, oh, we have this tremendous surplus of over a billion dollars, right? And of course, the public worker unions go, okay, fine. We know exactly what our marching orders are. And we want some of that. And don't tell me that you don't have money because you just said you have money. And then the very next month, the administration goes to all the unions and says, oh, you know that one billion dollars we were talking about? It's already all gone. Yeah. Yeah, we've already spent it. Yeah. So it's not there anymore. Because the union had a place for it. No, no, no. It went to fund like unfunded liabilities or it went to, you know, this reserve or that or something. You can always find ways to spend money. I know that at home. Oh, yeah. It's Tommy Yamachika, president of the Tax Foundation of Hawaii. We're talking about his article in Civil Bee. We're talking about the legislature. And when we come back, I really like to get into what Kan Kan might have done or might do, might do if there is a Kan Kan in order to ameliorate these problems. Can you wait? You are? Okay, we'll be right back. This is Think Tech Hawaii, raising public awareness. Every Monday afternoon from 5 to 5.30, Hawaii Standard Time for an insightful discussion of Contemporary Asian Affairs. There's so much to discuss and the guests that we have are very, very well informed. Just think we have the upcoming negotiation between President Trump and Kim Jong-un. The possibility of Xi Jinping, the leader of China, remaining in power forever. We'll see you then. We're back with Tommy Yamachika, president of the Tax Foundation of Hawaii. We're talking about balancing the budget, talking about his article in Civil Bee, talking about Kan Kan and what it could do to help ameliorate these problems around our budgeting difficulties. Yeah? Well, what you have to realize is that all of the provisions that I talked to you about, the one about rebating monies to the people about the expenditure ceiling, we also enacted a debt limit and a balanced budget provision. Those all came out of the 78 Kan Kan, all of them. They were trying to restore some semblance of responsible budgeting to the legislature because at the time it was perceived that you've got to do something otherwise the legislature can go out of control. Boy, did they have a point? But the problem, I think, was that the provisions that they enacted, they basically had no teeth. The provisions basically said, well, okay, you need to state your reasons why you're not doing it this way and you need to maybe have a few more votes, easily done. Easily done. It was very easy for the legislature to beat these provisions into submission, especially if we in the electorate weren't watching or didn't raise a fuss and we didn't because that's not the kind of people we are. What could be different this time? One, we could have a Kan Kan and we could enact some fiscal provisions that actually have some teeth in them this time because we know from experience that you put something in there, it's aspirational or if there's a really low hurdle to jump, I'll jump it. That's what experience is taught us. Or we as a people have to be more vigilant and we have to know when these departures from sound fiscal policy surface and we've got to say something to make sure that lawmakers told the line. We can't make it so that they can jump over the line without consequences. There have got to be consequences. The tax foundation is involved in this what every year all the time. We try to make sure that people are informed so they can make good decisions about how to proceed or how to follow what's actually going on in the square building. Let me make you the Kan Kan. Let's assume for this discussion that the vote on the Kan Kan is positive in November two weeks from now and they see these problems and they try to tackle them. What sort of amendments would you want, would you like to see to create a greater fiscal responsibility? Well, I'd like to see an expenditure ceiling with some teeth to it. The provision that was put in in 1978 was expenditure shouldn't be growing faster than the rate of the economy. And if there is some kind of dire emergency then yeah they can break this but it's got to be some kind of dire emergency and it's not something that you break routinely or every year or every two years. Even back in 2001 when we had the fiscal with the Felix consent decree that was creating lots of more costs for the DOE we should have realized that that is now a cost of providing education and we should have figured it into the budget rather than just busting the budget. You're talking about the budget as a mathematical experience but at the end of the day query in the way things work right now can we pay, with this economy, the size of the state, the population of the state, the skill set of the state, can we pay the 40 billion or whatever it is in unfunded liabilities in a timely fashion? And I'm thinking of Puerto Rico and I'd like to raise that with you later but are we able to do this? Some enterprises can't pay the bills. Can we pay the bills the way it's set up right now? If there's the easy way and the hard way. The easy way is we raise taxes, we raise taxes a lot and we beat up everybody. Will there be consequences? That's the issue I put to you. If there are no consequences that's what they'll do. You make a chart, you say up to X there will be serious consequences so we'll raise it up to X but if it goes beyond X and there will be serious consequences then we won't do it because we don't want those consequences. One consequence would be said legislators who vote for this taxing provision get tossed over their ear in the next election. That's one consequence and other consequence is people start leaving the state by the drugs which has already started happening. There has been a net out migration of people from the state and some legislators don't know this or they're in denial but this is actually happening. This is very bad for the economy and the ability of the state to raise money. The fewer people we've got the more of us have to shoulder the burden. The fewer of us are left to shoulder the burden so more falls upon each of us. You have to be careful if you raise taxes but would you raise taxes a little bit in order to deal with these unfunded liabilities? The other way is you go into these departments, you come in with a sharp pencil or a sharp knife and see what kind of fat is in there. With these really big departments you're probably going to find something because I think there have been studies done and you have big organizations, you have more waste than abuse. It's easier to hide stuff. When Maria hit, Puerto Rico was in bad shape anyway. They had suffered a default on their state bonds. They were something like 80 billion dollars in the hole for a population of something in the order of 3 million which is a little more than twice of what we have. We can't go there.  That's a disaster. We're almost there now. What worries me is that we could have a storm just like they had and of course FEMA will help you hopefully. The White House will help you hopefully but you really would like to have a rainy day fund literally in order to rebuild the state and build it better which is more costly than simply rebuilding it and taking all those steps to deal with sea level rise and climate change and the homeless, all the unfunded liabilities. We need something really remarkable, something dramatic to get us out of this kind of mindset of everything will be fine. What is that? How do we do that? How would you do it if you were running this concan? Would you, can you, would you take existing state liabilities such as the one you mentioned to the retirement system, the ERS and say, we know that you've been counting on X benefits but you know, we don't have the money, we're going to have to reduce those benefits. I'm guessing here that I think a concan could do that and that might save us several billion dollars. That's a possibility. I mean the existing protection for the retirees and stuff is contained in the concan. Constitution now, so it would need some kind of constitutional action to change that.  You can't touch the monies for the liabilities that were promised to the retirees. Under the constitution you can't touch them. Even though there's an emergency and you need money for emergency services. And then there's OHA, you know, I mean a lot of people have, connect OHA with concan either on the side of OHA, it costs too much, it's a waste, it's inefficient, it's corrupt. So we should knock it off and save that money and I think there's a lot of money that goes right off the top into OHA. Or other people are afraid that OHA will come in there and try to ask for more money, not less. And so there's a sphere on both sides and I think it plays in this concan in whether to do a concan. Do you agree that OHA is a principal object in the conversation about whether we should do a concan, what would happen at a concan? I'm not so sure the principal object is OHA, I would focus more on DHHL. Because DHHL under our current constitution has a requirement that they be adequately funded. And there was a legal dispute that was going on between the branches of government, you know, I forget the name of the case but it was a big case regarding the alleged underfunding of DHHL for the last several years. Now one problem is that DHHL hasn't been able to spend their money. It hasn't. It hasn't. They were getting money from I think some federal programs as well, they weren't spending the money and the feds were saying, okay, well, if you're not going to use it, we won't give it to you. So that's fair. Yeah. But tell that to the 20 or 30,000 people who are on the waiting list for Hawaiian homestead. You've got a failure of the agency as well. Well, that calls for leadership, it calls for the GADFLY, calls for the tax foundation and similar organizations. Go out there and find out whether our tax money is fair and whether it's being used fairly. And I think one of the problems is that you say the word tax, people fall asleep all around the room and nobody really wants to roll up his shoulders, nobody but you, and figure out what's going on and make it right. And as a result, there's a certain amount of uncaring complacency in the legislature and in the public arena about something. Yeah. Now, one, I think good thing about OHA that you mentioned, OHA, is that we, the general electorate, get to elect the trustees. And I think there have been more trustees who are, especially the newer ones that are coming in, who are worried about the future of OHA and how it's been expending the resources that it has been, and they want to shake things up. And they just need the votes to do that. Yeah. But I think it's a large part, it's educating them, it's educating the legislature, it's educating the agencies, it's getting everybody in the same boat, you know, with the sort of altruistic greater good view of things and certainly educating the people so they don't blow this off. And so you're doing very important work. We try to. Tommy Omicica, President of the Tax Foundation. Thank you, Jake. Thank you for having me on the show. We'll have you back soon. Thanks.


Yep, I mean I think really good is just to be able to, you know, do some things that are really positive to mask some of the stuff that is just going to cause you to lose, which we all know what those are. The poor fundamentals, poor tackling, penalties, you know, protection, you know, issues not given Derek enough room in a run game.  But when we had to have plays, we had them. You know, impressive to be able to go out there and, you know, get a stop and when we did, impressive to be able to take the football and control it the way we did. Mike, you really seem, I know you're looking for defense to make plays. You got an early turnover. You got a big goal on stuff and then you got to turn over late. I mean, how key was that?  But, you know, start the game like that with a hammer and a bang bang play. Fantastic, you know, but there's just too many things. And I know that the players will echo this sentiment. There's too many things that, you know, we have to clean up and be better. You know, we have to just stop the run. We got to get off blocks, set edges, not dive and go off the diving board and miss tackles and, you know, that's what it comes down to in the run game. Lying up and trying to beat somebody and shed and make tackles. So give them credit. Mike, what did you make of the way that the game thought called today? It seems like there's a lot of creativity. You mentioned, you know, all the credit goes to the players. Ben, I don't, you know, watch all 16 games from this week. A lot of the players are going to look the same. It's the players are the ones that make it go. Cover one, cover two, cover three, cover four, so on and so on. Zone right, zone left, gap scheme, you know, mix in some zone read. A lot of plays that are similar. And what happens in this league is that when guys know things and, like, you know, they understand what's being asked of them to do and they're taught well and they can go in there with some confidence, you know, that's what makes it go. That's what makes the play call go. Well, it's always been, and I know this is your first year, but it's all with us, you know, guy calls a play. It's got to go into huddle. And at that point in time it's up to the 11 guys in the huddle, you know, the quarterback to echo it. And I thought we did that a fantastic job down in the red zone.  But ultimately, you know, Ryan had to get guys the football.  And so Ryan was able to see it. So credit to Todd, I guess, yeah, great call, but then the execution by the player. So that's what it comes down to. And from a design perspective, there were more bunches, more stack. How much does that go into, you know, these guys running freely because it seemed like they were doing that a lot more today? I mean, just trying to create ways to, you know, get guys open and catch a run and hold up in protection and, you know, even Jeremy helped us out there on third down and catch and run.  How much was just to kind of stay in the fight? It seemed like both sides, you know, kind of took some turns early jab and you guys kind of warmed down and that 17-0 scoring supporters in the middle of the game seemed like that. I mean, I think that's a lot of how it goes, especially in this league and its division. You know, they're a talented football team and we're going to have to move on here to another very good football team. But that's kind of how it goes. You got to stick around and, you know, you have to be willing to take some punches in this league to stick around. Like, no front runners shouldn't show up because guys aren't going to go away, teams aren't going to wield on their own. You're going to have to continue to push and pound them, you know, until you get some breaks. The play at the goal line, you have to watch the film. It seemed like Tard penetrated. Yeah, from my knuckle, from my knuckle that he punched, it felt like Tard was very impactful in that play. And that's the expectation for Tier.  And I don't think that that's the case, but, you know, we've always seen something in him. And Big T has always seen something in him from, you know, the junior college journey for however many places that was, and, you know, we just keep coaching him and teaching him and focusing on his conditioning because we understand that that's the type of impact that he can make and the type of plays that he can help us make. Marcus Johnson just, you know, he's having a great camp and then he has the injury and all that kind of stuff. You mentioned how good it was to see him, you know, perform and help you guys out today. Just wondering if you could touch a little bit more on just what it was like to see him out there today playing. Yeah, it was great. You know what I mean? He's a fluid mover. A quarterback really developed some trust in him during training camp where a lot of those relationships are formed.  So he can be engaged in the meetings, but he's not catching any passes from Ryan. And so the ability to get him back practicing last week on a limited role, you know, and then this week, they did plenty of work, you know, to be ready for today. In the first half, what happened on the... Hold on, Buck. From your experience with Irving College, what does he still have to sort of learn to make that transition to you? I can only coach one team at a time. I'm focused on the Titans. What happened on this one? Should have went to you first. What happened over the last game of the first half? We didn't snap it in time. Ashley, missed you. Got a lot of moving parts, Buck.  You know, I mean a group of receivers and Titans and, you know, we got to get the personnel right. We got to, you know, communicate that and then get the right group out there and that starts with me. And we just, you know, those are all things we got to clean up, man. That's a long list of stuff and you'd rather be able to do that after a victory than you would have lost, you know. That 58-yard run that Robinson had, was that just a matter of shooting the wrong gap or what happened there? Just a lot of things, you know what I mean? Again, we can always go back to when you stop the run. Edge, good edge. There's a wall, there's no creases and guys are swarming. And it looked to me like there was a crease and so that was, that's not going to leave good results. I'll have to get that fixed and corrected and move on the next week. I think that they're going to compete, you know what I mean? They're going to compete, they're going to fight. They have high expectations of themselves. I mean, I've learned I love coaching them. I love coming to work every day and coaching them and building relationships. So we're going to learn that we've got to get better too. Thanks guys.


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