I’m on Medicare, but I still got stuck with a $25k hospital bill
spokesman.com
spokesman.com
If I were in the US, travelling, I'd only want immediate life saving treatment (a heart attack, say) to take effect unless I was absolutely sure of the precise cost of what I was submitting myself for.
It baffles me that you can be billed unknown amounts for this. I don't do _anything_ without knowing roughly how much it costs. My rent? Known before signing. Utilities? Rates are published, there's a meter on the wall. Supermarket? Prices are right there. Taxi? Has a meter, or it's fixed price private hire.
The only example I can come up with right now where prices aren't generally known before the fact is the pub. If you serve me a pint and claim it costs 15 quid rather than the expected ~5, you better believe that you're pouring that down the sink.
I drove by a road toll today in Norway that cost $1. I'm given enough time to turn around and decide not to use that road.
Yet Americans are getting slammed for multiple years' income whilst they're essentially unconscious?
Absolute madness.
It would be impossible as even doctors and hospital staff straight up don't know what is covered and what isn't from person to person with much confidence....let alone the actual pricing.
Heh.
If not... why are we brainstorming ideas for an auxiliary medical information business whose apparent business model would involve fee for service to prevent beneficial-if-expensive medical interventions? That's arguably a step down from ideas to get people to click on ads. It really seems smart people out to be able to enjoy working on the hard problems of brainstorming contributions to a medical system in which effective providers are reasonably trained and rewarded, insurance risks are effectively pooled and managed, and access to care doesn't carry a risk of bankruptcy.
I think you just described medical insurance
You can set yourself up to be judgment-proof, and hospitals can perform all the unwanted care they want to on you and they'll be able to collect basically $0. It's easier than it seems - move to Texas, leave all the assets in retirement accounts that you can, and plow all your liquid wealth into your primary residence.
If I go on holiday to the US, and for whatever reason through some minor flaw in my travel insurance (or just not having it; I imagine millions of people fly there without it each year) I'm not covered, it sounds like a person could easily rack up tens of thousands without realising if they weren't aware of this sort of thing.
That kind of situation can be avoided with International SOS insurance, on top of travel insurance.
Basically, it is medevac (helicopter or small aircraft) insurance that repatriates you back to your home country.
Besides even if 0.1% goes disastrously wrong financially then that's still a lot of people.
In Australia, the number one reason for personal bankruptcy prior to the Hawke Labor government introducing Medicare in the 1980s was unexpected medical expenses [1].
insurance is the USA is largely tied to having a job. You can buy your own insurance but it's terrible in comparison to better employment-based health insurance and the reason for that is exactly why we need a public safety net.
Company insurance plans a) form a group and b) have negotiating power with insurance companies. The first part is really important. Being diagnosed with diabetes and then having diabetes-related medical expenses be excluded from personal insurance as a pre-existing condition is Bad. Really Bad.
The only way insurance works is if you consider the total expenses of a sufficiently large group of people. Companies, unions and government organizations are the only way to get this in the US.
[1] https://www.abc.net.au/news/2019-05-18/bob-hawke-what-did-au...
Getting hit with surprise medical bills is very common among my network.
Personally, I went for a physical and hospital billed me over $600 for it. They apparently performed things that are not covered by my insurance.
No matter how much you insist, hospitals won't tell you how much things would cost or if something is covered or not.
I try to be proactive about my health but surprise bills sometimes scare me out of visiting hospitals/doctors for checkups. Or even if I go, I'm always worried about getting surprise bills weeks later.
Remember, medical bills don’t mean anything on their own and doctors want to get paid.
"$800 is what we think you owe us," isn't even quite the right explanation.
It's more like, "we think you're an $800 sucker who will cough up that number because it appears on this official-looking piece of paper."
And if you call one of them up (any of them: doctor, insurance, hospital, whatever) they're going to either: a) tell you to talk to one of the other two, or b) exactly what they think you need to hear so that they maximize their conversion rate, i.e. so that you send in your real money for their fake bill.
Did you put down your signature on a piece of paper stating to the effect that you owed them $800? Do they have in writing your acknowledgement that you supposedly owe them $800? No? Then why are you acting like it?
Collection is their problem, and right now they're playing a psychological trick on you because on works on people like you.
patio11 has some good comments on collections. I'm not going to dredge them up but anyone sufficiently interested can do so.
It's really unbelievable anyone would ever agree to pay ridiculously high sums someone else just pulled out of thin air post factum. It's unfair, it's absurd, it's breaking people's lives. Why don't you collectively decide to end it once and for all?
It's for this reason that most countries have some kind of mandatory insurance against emergency medical treatment where the person being treated basically has no choice (even if they're conscious) and is thus incapable of forming a valid contract.
You're right that in this scenario it's weird to expect someone to still pay for their treatment, but if you can't force people to be fully insured against such costs you need to force them to pay for costs they couldn't freely consent to.
Or if a UK citizen drives a car with (unknown to them) invalid insurance and destroys the side of a house or whatever.
The NHS charges at 150% of their standard charges for non-EU nationals. For most people this is a moot point since short-term visitors are required to have insurance anyway, and long-term visitors pay a surcharge which covers them for all NHS services.
https://www.nhs.uk/using-the-nhs/nhs-services/visiting-or-mo...
I’m glad to learn that people in reality though, do get taken care of when in need. Anything else would be highly unethical, really. Life > debt.
With regards to your hypothetical scenario as a Norwegian citizen: are you sure your Norwegian social security wouldn’t reimburse you in case of emergency treatment in the US? I know for a fact that Austrian social security would be pretty much obliged to (I would guess it’s the same for many other EU countries).
https://en.wikipedia.org/wiki/Emergency_Medical_Treatment_an...
The fact that providers can perform services on you without telling you up-front what the price will be is the problem. That isn’t how a lot of the rest of our capitalist society works - Amazon can’t raise the price of something I order from them after it’s shipped to me, my rent can’t change once I sign the lease contract which clearly states the charges up front, and so on...
Of course. In an unregulated for-profit health care system that is definitely the problem and the way we got there was because of; if there are multiple vendors then prices will automatically go down.
I'm not anti-capitalism. It just doesn't work for certain parts of society but it seems that in the US everything needs to be capitalised and the government clearly doesn't want to regulate this industry.
FTA: “In a feeble attempt to ameliorate the problem, Congress passed the Notice Act in 2015, which requires hospitals to inform patients of the implications of their observation status within 36 hours after observation services have been initiated. In other words, hospitals must advise patients of their observation status only after they have already incurred the expense of surgery and hospitalization.”
This type of thing seems like the most immediate problem. It makes no sense that the price can be raised 36 hours after a procedure has already begun. How is anyone supposed to negotiate that properly?
Just saying, I don’t think “capitalism” is necessarily the boogeyman here. The government itself is failing to negotiate properly with the providers when running its socialist healthcare system in this instance. (And non-government payers will run into the same problems, getting unfair bills that couldn’t be anticipated or negotiated before agreeing to the service)
Any market where the buyer is not the person who’s paying, or where the buyer has to make a purchasing decision before they know the price (or even what goods/services they’re agreeing to buy), cannot possibly be influenced by the laws of supply and demand. It’s the same reason that you can look at essentially any government spending project, and amaze yourself by how little the government manages to achieve with so much money. The payer doesn’t have any choice about how much taxes they pay, and the decision maker has a very poorly constrained supply of other people’s money to spend.
Perhaps the real issue is the lack of capitalist principles? Perhaps the issue is CMS trying to micromanage everything via billing in a very centrally planned manner?
I think its interesting that the areas of the economy with the most government intervention are doing the worst... Healthcare, education, housing...etc. You could even throw in ISPs with their government guaranteed monopolies.
Meanwhile tech had basically no regulation. What do we see? Many things are free (yes even to the poor! Without a government guarantee or people going around proclaiming that it is a human right! Insane!). The industry also has some of the highest paid (no tech minimum wage to bring it about, insane!) and best treated workers...
I think it's the opposite–yes, the government does allow this sort of behaviour, but that's because the health-care-adjacent parasites lobby so furiously against any efforts to stop it. It's scarcely the government stepping in to ensure this sort of banditry (why would they, when government officials don't benefit from it?).
What?
If you have an exorbitantly expensive medicine that is covered under Medicare Part D (extremely, extremely likely), then you will face something called Medicare Part D catastrophic coverage. One should especially look into the data on that.
It is really easy to be in the Medicare Part D catastrophic coverage situation. Even if you are sitting on a mountain of cash during retirement, it is profoundly wasteful to be paying anywhere from $20,000/year-$100,000/year for your medicine, which is usually a lifesaving medicine, and is life or death, whether you take it or not.
Not to mention: The third leading cause of death in the United States in preventable medical errors. If you do not believe me then Google it. When a country has the third leading cause of death as preventable medical errors, they are almost always developing or third world countries. But, the US is an anomaly in that respect.
You can go the the best hospitals and the best doctors in the United States, but you cannot evade a statistic like that. When that statistic is so high, these issues are so pervasive that they are definitely present in a completely unacceptable way, even with the best institutions, hospitals and doctors in the United States.
If one was smart, they would investigate this further and decide to leave. Europe, especially West and Northern Europe, should be places one should by vying for. But anywhere in the European Union typically will be a step up from this chaos of a system.
I googled it. The third leading cause of death is 'accidents.' Where are you seeing 'preventable medical errors'?
There has been a lot of research done about it. It would be foolish to underestimate the scale of the problem.
Also, if you are concerned about getting the best possible care, or even just staying alive long-term, one should spend a lot of time examining http://healthdata.org
Life expectancy can be a good start when it comes to just investigating things.
The research from this site is very solid and all of it is open access. It was funded partly by the Bill & Melinda Gates Foundation too. A lot of this research comes from the University of Washington. They have a remarkable statistics department in general. They also have an phenomenal medical school. In terms of public medical schools, it is by far one of the best. Only UCLA and UCSF compete with it. Their allied health programs are great too.
If you live in Seattle, the care tends to be fairly consistent. Anyways, I am basically affirming my allegiance to UW Medical School. They kept my grandmother alive for many more years than what we would have ever expected.
Anyways, you can bet on it that their research is solid, even though I have deep respect for UW Medical School.
You are correct. It took her two years of study (with full time job) to pass her medical coder exam, and she's only really an expert in her area of expertise. There are dozens of areas of expertise. It is virtually impossible to navigate the system without an insider to assist.
On first glance it seems like only the well-off would go to college. I won’t respond further unless I’m sure I understand your proposal
Sounds ridiculous right?
So the make the price $30.000 and give discounts if your parents don't make $100.000 instead.
Education loans just bring more money into the system and inflate tuition, just like how 0% down mortgages inflate real estate prices
I don't think anyone is opposed to letting people buy private insurance on top of the obligatory single payer. Does any country actually ban additional private insurance?
I wonder how travel health insurance works for tourists there.
“ In fact, the bill would outright ban private insurance that provides similar coverage to the new Medicare for All plans after a short transition period. That means everyone with comprehensive employee benefits or a private plan through the Affordable Care Act today would be moved onto Medicare.
[. . .] Sanders has said he envisions these remaining plans covering a handful of items like cosmetic surgery that are left out of Medicare. For everything else, the only option is Medicare.”
Since private insurance is willing to pay far higher rates than Medicare, this would lead to Medicare-for-all failing. Doctors already exist who refuse to accept Medicaid-insured patients because the reimbursement rates are low compared to privately-insured patients.
Everything I can read about this plan says it would ban plans “on top of” Medicare, and contrasts it with other countries like the UK, Canada, and Denmark, which do have supplemental private coverage for medically necessary services available.
As a physician, you have to pick either the public or private system. You can’t practice in both.
Single-payer does not mean abolishing private insurance.
Take the UK’s NHS for example - there’s a thriving private healthcare insurance and private healthcare provider industry there.
Trump’s bill is about price transparency - while the bill is not a bad thing it won’t solve the problem of inflated prices to counter insurance lowballing - I believe the end-result will be something like the “room rate” signs you see in hotel rooms in many states that show the maximum legally allowed billable rate for the room which is usually very high compared to the rate you’re actually paying.
As for the cost argument - people will NET save money because the tax increases to pay for universal coverage will be less than most people’s current healthcare expenses (assuming employers will pass on the savings from not having to pay for workplace health insurance as salary/wage rises for everyone).
Not to mention, the third leading cause of death in the United States is preventable medical errors. If you do not believe me, then Google it. You can go to the absolute best institutions, hospitals, and doctors, but you cannot evade a statistic like that. It is way to pervasive. Our healthcare system, along with is quality, are absolutely deplorable.
But the good news is, most people on here are educated and are skilled workers. They can emigrate to other countries. I would recommend the European Union countries in general, but obviously Western Europe and Northern Europe are better. But, anywhere in the European Union really is a step up from American-style care.
I am a European Union citizen. I am Croatian, besides being American. I am leaving the United States soon. I cannot wait to start a new life and adventure. I am tired of living in fear about my healthcare.
>you cannot evade a statistic like that
The best advice I tell people is to make sure you have a patient advocate (family member or friend) with you 24/7 when you are hospitalized aka "in the system". I stayed with a friend for a one week hospitalization and witnessed multiple preventable medical errors that could have resulted in intubation and admission to the ICU (and perhaps death). I had to physically intervene to prevent the administration of a contraindicated drug which my friend had explicitly declined. I had to diagnose and fix faulty bedside telemetry myself. I had to retrain the CNAs on how to accurately collect sublingual temperature readings. The entire experience was quite eye opening. I've never spent time in a hospital in Europe but I would be surprised if the benefit of an advocate was not somewhat universal.
While what you said is absolutely true, there are serious breaks in continuity of care that allow for these things to happen too. Not having a true standardized health record (versus something that is effectively a billing machine) that can be accessed anywhere, by healthcare professionals, and without obstacles is extremely disastrous.
This needs to be studied more.
What I am trying to say is that staying in the hospital 24/7 as an advocate may be a necessary and needed remedy, besides being something that should be necessary in general.
But only works as a remedy in the most basic sense.
I have a background in the sciences and was premed myself, so I am familiar with the medical field (completed premed coursework to attend medical school + know the process for becoming a board certified and practicing physician) and am passionate about healthcare and human centered design (have years of doing great UX work in tech and pharmaceutical companies). Contact info is in bio.
Would love to talk to anyone else interested in this to get something going and working on solving these problems. My dad had a hemorrhagic stroke and I'm bedside every night and passionate about making sure his care team does their job and prolongs his life so we can get out of the hospital and on he road to recovery. I would love to scale this up to patients in hospital beds globally and save lives from avoidable medical care mistakes and oversight!!
The doctors may be phenomenal and unbelievably amazing. But when it comes to general care, I have serious doubts.
This stuff is frightening, if I wasn't here he would surely develop a life threatening infection in his immunocompromised state (he already did a course of antibiotics for something he picked up from the hospital environment.. pseudomonas?)
To them he is just another patient and a number in the system. I've seen them cut corners and get frustrated doing their job (having to change him etc) and talking behind our backs in the hallways when I'm getting on their case to get his BP meds ASAP and notify doctor (high blood pressure >160 systolic is BAD for hemorrhagic stroke patients).
Anyone have any tips or resources for how I'm supposed to be optimizing his recovery and shield him from mistakes of his care team? Thanks, this is really taking a toll on me and I'm trying my best everyday to make sure he gets out of the hospital setting and on the road to recovery. I've been by his side every night switching with another family member for 24/7 coverage for months now.
I am sorry that you are going through this. You are a wonderful son/daughter. I am sure your dad appreciates you in an incredible way.
Obviously artificially intelligence has been overhyped. But what it really is especially capable of doing at this point is preventing human error.
There are lots of various things that could be done. I am not focusing on purely AI as one has to be open-minded in the design process.
I will contact you in the morning.
sorry if I'm slow to reply, my sleep schedule is all over the place but dad is being discharged soon so I promise I'll get back to you soon, added my email to bio.
And even if they do, it typically takes 1-2 years after it’s approved before they’ll pay.
Yes the US system is terrible and expensive, but one reason it’s expensive is because it’s rare for them to say “no”.
> And even if they do, it typically takes 1-2 years after it’s approved before they’ll pay.
This statement is very untrue for Germany. Germany brings medications to market typically very quickly after approval.
This is especially true in the realm of rare diseases (which are common: 6-8% of the general population has one) where access to these medications is often a life or death matter.
There has been research on stuff like this. I would look in to it if I were you before making assumptions. There are also other countries in the EU that do well with this.
In the US, drugs are typically reimbursed the day after approval (though it can take a few weeks for manual approval).
And because the process is so onerous and the GBA fights on price, some drug companies are choosing not to launch in Germany.[1]
[1] http://www.pharmafile.com/news/166284/boehringer-lilly-wont-...
First, these medications are absolutely never reimbursed the day after approval in the United States.
If you get a prescription for a medication the day after approval from your doctor, the insurance company will almost certainly (practically a 99% chance) call the medication "experimental" and "not medically necessary", and deny all coverage of the medication. You will have to appeal the denial, and you will be extremely lucky if you do get approval to take this medicine. To do so, you have to write an extremely detailed letter, very cohesive and without any sort of mistakes that give it any uncertainty. You basically have to tell them that you will either cost more to them than the cost of the drug, if it is not approved by them, or die.
If you are "extremely lucky" your insurance is (almost) guaranteed to send your doctor a prior authorization request. This takes weeks to resolve, if not months. This is basically a request so that a a bureaucrat from an insurance company can "give you permission" to take this medicine. If you are "lucky" it gets approved. There are people who are denied approval just because they have another condition (that is off-label) in addition to the FDA-approved condition that the drug was approved for, just because this was affirmed in a check box in the prior authorization. It is straight up incompetency. Also, doctors reviewing any sort of appeal or prior authorization are practically guaranteed to be practicing medicine in a board-certified field that is completely irrelevant to the condition you have.
They can also deny you the recently approved medicine because they require you to do step-therapy first, and sequestering this medication as not being an option for a very long time. This means that you must try a cheaper and less-effective medicine first, putting you at risk of having your condition worsen in potentially devastating and irreversible ways, before being able to try more effective medicines. So, patients with devastating conditions like multiple sclerosis will often have to go through a series of trials of less effective medications, often with their conditions worsening in an irreversible way, just because their insurance says so. There is no way to legally get around this in the United States as a patient.
To top this off, more than likely, the medication will not be put on the formulary. Pretty much all insurance companies in the US subject their subscribers to a formulary. A formulary means that you cannot take certain medications under any conditions, and the health insurance company will not cover the medication under any conditions whatsoever. It will absolutely be denied, no matter what. There are tons of medications that have legitimate medical uses, that are excluded from insurance plan coverage, even in the case when there is no alternative for it.
Between automatic denials, prior authorizations, step therapy, and formulary exclusions, which are standard practice in the United States, it is guaranteed that one will not get the needed, recently FDA-approved medication, for months at best, but in reality, it could be several years, or even never. They do let people die in life or death situations all the time.
Regarding Germany: By the way, orphan drugs (rare disease drugs) dominate current regulatory approvals, being the vast majority of current drug approvals.
These medications typically cost hundreds of thousands of dollars per year, if not millions per year, now in the United States. This is not the list price of the medication or the amount that was billed to insurance either. This is the reimbursement rate by insurance, that is paid under contract.
Countries like Germany have no issue paying for them, and they are reimbursed much quickly than you claim.
https://www.sciencedirect.com/science/article/pii/S109830151...
Yes, not all insurance companies in the US approve the day after. But some do (I’ve personally witnessed it). How else would newly launched drugs have sales in the first quarter? People sure as hell aren’t paying cash.
Since it’s before a policy is formally written, it’s often a manual approval based on medical necessity. The issue with PA denials is separate from actual reimbursement, Germany has PA requirements too (as they should, why pay for a new drug if an old drug works just fine). I never said it was easy, I just stayed they are paid for quite quickly.
A drug I recently launch was approved by the EMA last year, it’s still not available in many EU countries because reimbursement hasn’t yet been approved.
And yes, the drugs are expensive, but at least with orphan drugs, they still cost hundreds of thousands in the EU. The price window for orphan drugs is quite narrow between the US and EU.
It seems that he only had Medicare Part A, which is not alone really health insurance it is strictly for hospitalizations and has no premium. I think of it more like catastrophic insurance.
Medicare Part B is actually health insurance and requires a premium. He casually mentions that he didn’t have Part B but unclear why.
The 20% coinsurance he paid is what you’d pay under Part B, and unclear what other insurance he has, but for a high earner you should always buy Medigap which reduces the 20% since like in this example can still be thousands of dollars.
> I wasn’t enrolled in Part B, but did have Blue Cross/Blue Shield supplemental insurance, which required me to pay 20% of the allowable hospital and surgical charges.
Medicare Advantage is just A+B from a private insurance company.
He really should have known that Medicare is relegating certain hospitalizations to Part B. This is very common and not new news. However, the rules involved with it, from the ER to the actual floor, are really strange and take a lot of time to understand.
Yeah, you have to know and understand a ton of ridiculous rules prior to going on to Medicare. It is an unbelievable waste of time. Then, once you are on Medicare, you have to continue to keep a look-out of what is going on, including investigating certain rules, as things frequently change.
He has my sympathies as this sort of situation should never exist in a developed, civilized country, like the United States. But, he made a series of mistakes, passively mostly, which got him in to this situation.
Some how nearly everyone in France manages to deal with buying top-up insurance for the 20-30% of medical costs the national health insurance doesn’t cover. This isn’t a uniquely American thing.
i am not surprised to learn that seniors are also exposed to some goofy backdoor likely engineered by some clever lobbyists ages ago.
from where i sit the risk of existential financial danger of being inside the US is probably not worth it for the vast majority of those no longer earning a normalish W2 income. what's the point staying in the US for "retirement" when you can get clobbered by some technicality?
some people may figuratively and literally live to fight another day but you'll probably do battle with this monster until you die warding off literal mercenaries trying to get you to pay the bill... and whatever assets you have tried to build up over the years as well.
given that a large percentage of the US economy is based on this behavior (and not really getting any smaller; it's big source of jobs - check job growth reports), it's fairly unreasonable to think it will get better before it gets worse. i am not optimistic that even if Sanders were elected he could fix this. there are too many grubby hands in the money pot, and it is too easy to sell the people on the """cost""" because second order effects (lost productivity, mental health issues, crime, ability to change jobs/situations without fear of death or permanent ruin, deleterious effects on youth without access etc.) are completely ignored. big numbers on federal budgets are too easy for those of the Free Market mindset to fixate upon.
i would humbly submit that if you are worried at all about this, there are lots of opportunities to take a social security income and live out a respectable life and/or death in countries where you are not treated like a financial bloodbag to be reaped and tossed aside. a lot of these places would be happy to have your dollars and you'd also reduce your contributions to this system.
I urge you to, as a dual national of both the United States and the European Union (Croatia). I am also on Medicare, as I am disabled.
One would be foolish to underestimate this comment and the overall situation it describes. It is unwinnable.
You can very easily end up paying a fortune every single year during your lifetime ($20,000/year-$100,000/year) for medications that are covered under Medicare Part D, due to a clause called Medicare Part D catastrophic coverage levels, just so you can stay alive. There are people in the top 1% that cannot afford these sorts of costs during retirement.
To top it off, the third leading cause of death in the United States is preventable medical errors. If you do not believe me, Google it. You can go to the very best institutions, hospitals, and doctors, but nobody can evade a statistic like that. The problem is just way to invasive and ingrained in to how we give healthcare in the United States.
If you want to stay alive long-term, then the best thing to do is to emigrate, particularly to a European Union country. They never discriminate on the basis of health status (including the cost of your healthcare or care), but you do have to be able to work to stay on a visa to eventually acquire citizenship. Obviously western or northern Europe is more desirable, but anywhere in the European Union is a step up in quality from the chaos of our system.
They price and sell surgery directly to patients and employers. Whatever one’s view of their approach, I learned a lot from the episode.
When the 2008 crash happened, I listened to the episode and learned a ton. He always invites people with deep knowledge of the issues.
Let's give credit where credit is due on this: https://www.healthaffairs.org/do/10.1377/hblog20190625.97459...
"My wife and I are both physicians, but neither of us had any clue that this could be the case."
I am working on finishing my education, as I only have 1 year left of engineering school, in electrical engineering, before I enter the workforce.
I require a blood product in order to survive. If I ONLY had Medicare (I don't--I also have employer-based insurance through a family member), I can expect to pay around $50,000/year for my care, due to Part D catastrophic coverage levels. I can definitely expect to have to pay $50,000/year soon if the Affordable Care Act is abolished. Fortunately, I am a European Union citizen, but it would be tremendously sad to have to leave the United States, my homeland, over this.
I really cannot go on a Medicare Advantage plan, which might resolve this issue, as I have a very rare condition that only a few doctors in my area are qualified to treat. Most Medicare Advantage plans are HMOs too. You also cannot switch back to traditional Medicare ever, once you get a Medicare Advantage plan. I live in one of the largest metropolitan areas by population too. It puts me in a strange place where I can almost be guaranteed not to get the care I need. My care is unbelievably complex.
It is very common to be admitted to the hospital by Medicare under observational status. I am surprised that the person writing this article was unaware of this, but almost everybody outside the healthcare field is unaware of it. There are also some really, really strange rules with respect to emergency room visits and being admitted under observational status by Medicare. It also takes a lot of time to look them up and understand them.
The Medicare Part B premium is typically $135/month for most Americans. This covers 80% of your costs for outpatient care, doctors visits, medical supplies, etc., under traditional Medicare (not a Medicare Advantage plan). To cover for the remaining 20% (which you should get coverage for--you are foolish not to) you need to get a Medigap plan. Those can be expensive.
I know this is unbelievably complex, and is a huge waste of time to have to go and understand, to prevent yourself from getting in trouble, if you have Medicare. It is ridiculous.
However, the author was being penny-wise and dollar foolish. It is very, very common for people to explicitly elect to have Medicare Parts A and B if they have traditional Medicare. Saving $135/month over something that could get you in trouble is not smart in the American healthcare system.
Yes, his situation should have never happened, in a decent healthcare system. It is sad. But he did make some pretty big mistakes, especially considering he is a doctor. But, he did not deserve this.
You can change plans during the annual enrollment period, from October 15 through December 7. You can enroll in or switch advantage plans or just go back to plain Medicare.
If you're on plain Medicare, you can also switch to a 5-star advantage plan between December 8 and November 30.
https://www.medicare.gov/sign-up-change-plans/when-can-i-joi...
If I were to switch from a Medicare Advantage Plan back to Traditional Medicare, I could never get a Medigap (or supplemental plan) which covers the 20% that Medicare Part B does not cover. This is due to the fact that I have a pre-existing condition. Actually, I probably have 50+ pre-existing conditions from a medical insurance underwriter standpoint, but that is beside the point.
See: https://www.kff.org/medicare/press-release/in-all-but-four-s...
> Depending on their state, Medicare beneficiaries who miss these windows of opportunity may unwittingly forgo the chance to purchase a Medigap policy later in life if their needs or priorities change, OR IF THEY CHOOSE TO SWITCH TO TRADITIONAL MEDICARE AFTER SEVERAL YEARS OF BEING IN A MEDICARE ADVANTAGE PLAN.
This is a huge deal. I have type 1 diabetes plus 2 rare immune-mediated diseases that affect my peripheral nervous system. My insulin pump supplies are covered under Part B. A couple of my hospitalizations were covered under Part B under an "observational status". I used to receive infusions of a blood product in the hospital every 2 weeks that cost my insurance about $10,000 each time, under contract. I also need a couple of different infusions, although far less frequently, to stay alive.
So for me, unless I totally uproot my life and move to one of those 4 states that does not allow the pre-existing condition clause to preclude me from Medigap coverage, I am stuck on a Medicare Advantage plan. I am screwed. These plans only become more hardcore and strict.
I cannot be on an HMO, which many Medicare Advantage plans are. I have a very rare disease that maybe a few doctors can treat, even though I live in a huge, very populous city. I also need the doctors I currently have, which work like a team. I cannot afford the several prior authorizations and the delays that will happen from switching insurance.
I cannot afford to make a mistake. Switching to a Medicare Advantage Plan can be extremely problematic for somebody like me, due to logistical issues. They could cost me my life too, and that is no exaggeration.
I may have to switch to a Medicare Advantage Plan, as costs are capped and I have an exorbitantly expensive medication that I must take to survive. Under Traditional Medicare, under Medicare Part D, I am subjected to catastrophic coverage levels. I can expect to pay $50,000/year for my healthcare, if I lose employer based coverage through a family member via Affordable Care Act partial or full overturn.
In the case that I am forced to switch to a Medicare Advantage Plan, there is no going back to Traditional Medicare, due to pre-exisiting condition clauses in Medigap plans. That is extremely problemsome as it limits my access to doctors and other care, as I have a very rare disease.
Fortunately, I am a European Union citizen, so I can just leave. But, it makes me profoundly sad. What I mean is that I no longer feel welcome in my own country, my homeland. I have been in remission for a year now and I am close to completing my degree so I can work. I really want to work! But the United States makes it extremely hard for me. There are just way too many things tied to working, especially health insurance. It is really sad. My family is here, but I know I would be better off in Europe. Right now, I have been focused on language learning non-stop. Obviously you learn one language at a time. I am currently working on Croatian. All I can do is try to move on.
The only thing that's a pain about it is Aetna conforms to Medicare's policies on covered care, so if you want something and Medicare won't authorize it, you have to go to a provider who does not accept Medicare to get it. You can also get coverage from a provider who accepts Medicare when the treatment isn't covered by Medicare by switching from Medicare to a 5-star advantage plan, since Aetna would not longer be able to fall back on Medicare not authorizing it, but then you lose the medi-gap aspect, although that's not too bad because Aetna has OK out of pocket maximums.
Isn't there some precandent in law somewhere saying that one parting cant change an agreement after the fact or they would be acting in bad faith? Are hospitals acting in bad faith?
Of course, it is being fought because Trump is behind it.
Politics is the relinquishing of critical thinking in favor of the interests of political parties. It is a disgusting, corrupt ecosystem populated by equally disgusting and corrupt people.
The only way someone like Trump comes into the scene is because things have become so putrid in politics that people decide their only option is to send someone into the White House who is perfectly comfortable throwing feces around.
That's almost poetic. And quite accurate in my particular case.
Go back as far as you can find video of promises made by Presidential, Senate and House candidates of any political party.
Write down the problems they list and solutions they promise.
Here we are, 10, 20, 30, 40, 50 years later with the same problems, the same promises and the same incompetence and lack of action.
Election after election, campaign after campaign, we are promised the world and, in exchange for our votes, receive absolutely nothing.
Through that time every single politician becomes a multi-millionaire at the expense of the people they are supposed to represent and help.
Don’t blame a guy who chose to step into a pit of vipers covered in fecal matter for what, in reality, is a monumental failure of our political system and the elites who run it.
The fact that we don’t have a sensible healthcare system is not Trump’s doing. It is the result of 50 or more years of people voting for charlatans and scam artists. It’s embarrassing, it’s a disgrace.
Yes, Trump is uniquely capable of inducing projectile vomiting. However, the real obscenity is what the political class has done to this country during the last several decades.
Imagine being the guy actually trying to fix that mess. Do you really think decades of corruption, partisanship and incompetence can be fixed in a couple of years? And, do you think fixing this putrid mess is going to be, say, dignified and clean in any way?
No, the way you clean a putrid mess is you open the doors and windows and you get to work. It’s going to be horrible, disgusting, smelly and vomit-inducing. Eventually, if you persevere, things improve and you can go from throwing feces at each other to pretending we are civilized and return to decorum.
I certainly don’t agree with all of his views and some of his social manner makes me want to vomit, but I am glad we have someone at the helm who is letting all the stench out for all to see and continues to fight them hard despite having been covered in shit for three years. Few people could endure such a thing. This is a remarkable time to witness.
The real obscenity is what our politicians have done to us for decades. Anything Trump may have said or done pales by comparison. I wish people could stop, think and understand this fact.
If these things were actually good we would not STILL have every single politician talking about having to fix healthcare.
Look, I get that you hate Trump. There's a lot of that going around. No problem. The issue is not to be blinded by hatred and to try to be objective about reality. In my decades in business I've had to do business and work with lots of people I did not agree with and, yes, in some cases, didn't like very much. Life isn't a nice linear ride into utopia. It's a twisty, complex and sometimes unpalatable path through less than ideal choices and outcomes.
Trump, in this sense, isn't any different from anyone who preceded him, from Obama's lies about the ACA (I am still looking for my $2,500 a year savings...in reality our insurance costs QUADRUPLED due to ACA, coverage got worse, we could not keep our prior insurance and lost doctors) to Bush's stupid wars. This is life. We don't have to love all of it. All we can do is try to progressively make things better.
BTW, it is disingenuous to say that Trump has not done anything in three years. He has actually likely done a lot more than prior Presidents. If we want to focus on healthcare alone, here's a short article listing a few non-trivial important achievements:
https://nypost.com/2019/09/21/five-smart-ways-trump-has-impr...
I hope you'll read it because it is obvious your hatred for Trump has caused you to not be well informed on these points.
As I said in a prior comment, he takes me to the edge of projectile vomiting every time he opens his mouth. However, my aforementioned business experience has taught me to focus on results rather than style. The results he has delivered in three years --while getting dumped-on and attacked from every angle in way and at a scale never before seen in US history-- are nothing less than incredible. I struggle to comprehend how it is that this man is able to do so much while being under attack 24/7 by half the government and nearly all of the media.
Here's another list:
https://www.promiseskept.com/achievement/overview/healthcare...
> Trump hasn't done shit
I wonder how you might support this statement? It is patently false. I am a Classical Liberal voter. I do not align with either one of the two main parties. All I care about are results, not style. Drama is of no importance at all. Results don't lie.
If you can ignore your hatred long enough to read through this larger list, perhaps you can comment on how this is, to paraphrase your comment, "not doing shit":
Most of my friends are Democrats and some even call themselves "as Left as you can be". I've had many in-person conversations with them over the last few months. Once emotion is removed from the dialog every single one of them is amazed by how much this man has achieved. My own parents are Democrats. They are voting for Trump in 2020. Why? Because of what what he has achieved while being the target of the largest political attack in the history of this nation.
People who can set ideology aside are recognizing what's going on here and starting to understand who --despite the lack of style and decorum-- is actually working for them.
What we are watching is a Democratic party living in abject fear of having become so incompetent and irrelevant that there's a real concern they will not win elections for some time to come if they allow Trump to win a second term and, perhaps, achieve super majorities in the House and Senate. The Leftist Utopia --you know, the one Aleksandr Solzhenitsyn describes in The Gulag Archipelago-- will evaporate from this nation if Trump wins another term and delivers results at a similar pace for the remainder of this term and another four years. That's the reason for this political war. We are witnessing a seminal moment in US history.
Sorry, but you are wrong on healthcare. Please take a look at this sub-list and tell me how this equates with achieving exactly zero. I want to understand how one goes from a list of undeniable achievements in healthcare to concluding something like "He certainly has achieved exactly zero".
https://www.promiseskept.com/achievement/overview/healthcare...
This article goes into a little depth on some of what they have achieved and the significance of the various achievements:
https://nypost.com/2019/09/21/five-smart-ways-trump-has-impr...
Again, echoing your intent, I am having trouble understanding how, in the face of clear evidence to the contrary, people can believe he has achieved nothing on healthcare.
Look, we all agree that healthcare in the US is a disaster. I hope we all agree that Trump had nothing to do with that. This is the result of lies, political games and incompetence going back 50 years or more. Let's be careful not to attribute the disaster our political class has handed down decade-after-decade to a man who --as all evidence indicates-- is actively trying to fix it.
The reason these things are not addressed after decades of promises is that politicians work for themselves, not for us. It should cause everyone pause that every single election in modern history puts exactly the same issues on the table as the most pressing issues of the time. The incompetence and lack of results is, at the very least, embarrassing and at some level criminal. Anyone delivering these kinds of results in the private sector would be relegated to using a hammer to turn big rocks into little rocks.
Trump is a nasty SOB, but if you leave emotion out of the equation and look through the list of what his administration has achieved in three years it is very hard to argue with the results. As I said before, this is all I care about. The theatrics will be meaningless in ten years. However, the results will have long-lasting effects way past his stay in the White House. That's the part that matters, nothing else.
BTW, this isn't a discussion about who I might vote for, please don't get defensive. This is a good conversation so far, no need to go there.
Let me add something about healthcare. I'd like to suggest you are focusing on the wrong thing (as are millions others).
The US healthcare problem is NOT an issue of insurance. Not even close. That's the biggest fallacy and lie told by politicians for decades now.
Put in very simple terms: You cannot fix the US healthcare system with insurance. Period. It is NOT an insurance problem.
I don't care if we pass Medicare for All, None or the Pink Unicon Plan. Insurance is not the problem.
What's the problem?
Costs. Well, it's layers of issues really. In no particular order at all:
The cost of medical education is ridiculous. The government needs to get out of the student loan game and allow the free market to drive education costs down. Today a doctor graduates with $300K or more in student debt. This means, in no uncertain terms, that this person cannot work for a salary lower than what's require in order to have a hope of paying back that loan and, on top of that, having a life, raising a family, owning a home, etc.
BTW, my wife is a physician, so I have first-hand data on some of the internals of the business side of medicine.
The next problem --and this affects everyone, not just doctors-- is that our education system loads-up degrees with a bunch of unnecessary pork clearly designed to add another year, if not more, to the process of obtaining a degree. In other countries, if you study, say, electrical engineering, you are treated to science and engineering courses, you don't have to burn months taking myriad unnecessary general education, sociology or other non-engineering courses.
When a university is charging you $50K a year to keep you within their walls it is quite profitable to require you to take a bunch of other stuff with the excuse of these things being degree requirements. This adds at least $50K, if not more, to the cost of getting a degree.
Moving on from there, the cost of malpractice insurance is ridiculous. Of course, there's variance from specialty to specialty. The range is from $5K to $50K per year and it also depends on where the physician might be practicing (which State).
These costs are an important element of the equation that ultimately determines how much we have to pay to have a dozen people attend to us during a surgery or half a dozen people involved in emergency care, etc.
Then there's tort reform. Yes, things have been getting better, with some States doing better than others. However, the consequences of our litigious society is that doctors are forced to cover their behind by sometimes ordering all kinds of unnecessary tests and medicine. This costs money and that cost is passed on to the patient one way or the other.
Now you start looking at medicine at the hospital level and things get worse. The hospital employs a bunch of people with huge student loans and varying degrees of malpractice insurance and office expenses to cover. The hospital itself has to cover itself through expensive insurance. And then there's the regulatory burden of actually running a hospital. Costs pile-up and, once again, they are passed on to the patient.
Then we move on to drug companies. The cost of developing drugs and obtaining regulatory approval is massive. Some drugs cost in the region of $5 billion. The FDA mandates testing that costs in the range of $300 million.
Drug companies have non-trivial costs associated with dealing with the regulatory burden. In addition to this they have to worry about lawsuits as well, which means they have expensive insurance, people to manage this (entire legal teams) and the cost of occasional settlements reached in litigation. Once again, costs pile-up and patients end-up paying for them.
Medical device manufacturers are subject to the same equation. I once tried to develop a relatively simple medical device that would help millions of people. The regulatory burden and FDA costs were so high I dropped the idea entirely.
The reason the same drugs and devices cost less outside the US is that drug companies charge US patients for the cost of doing business in the US. This makes sense, why would a company charge the US burden in nations where they have a far lower cost existence?
There's more, but I'll stop here. For example, we could talk about the truly horrific medical patient data system that adds untold cost to our healthcare system.
The bottom line is that one could pass the most wonderful sounding insurance scheme and it would do absolutely nothing towards dealing with any of the above problems. Not one thing.
These are basic business problems. When things cost you too much you go back and analyze the cost structure that leads to high prices. Our cost structure is horribly high. Which means our costs to deliver care are equally horrific. Insurance will not fix this at all. It's like saying that changing auto insurance policies is going to reduce the cost of buying a Tesla. No, the cost of buy a Tesla is associated with the cost of making a Tesla and not with the insurance the owner will pay to drive one.
OK, here, I'll post the list here. This list is not exhaustive. You can google each and every one of these and find further details. This is far, very far, massively far, from your idea that Trump has not achieved anything in healthcare. The exact opposite is actually true, what this administration has been able to achieve in this domain while being under absolutely brutal attack 24/7 on the part of the Democrats and almost the entire media is, well, nothing less than remarkable. He still has at least a year to go, some think he has five. I can only imagine what he would have been able to accomplish under more favorable circumstances.
This political war has cost this country dearly.
He has lists like this one in almost every domain affected by Federal policy. It's simply amazing. People don't know about it because the media are so incredibly biased and one-sided that they hide it all, they don't talk about it, they only focus on the hatred. And so it isn't a surprise that someone can actually believe that he has done nothing, despite all the evidence and documentation that shows otherwise. I mean, you can literally go dig-up the executive orders and read them. This is real.
I hope you re-evaluate your belief system, because you are 100% wrong on this. You don't have to believe me, go dig-up the executive orders and read them. Everything below can be corroborated. No lies. You can still, as I, dislike his public persona, yet you can and should be honest enough to accept the fact that the results he is delivering are likely without parallel in modern US history. It's amazing.
- The Department of Agriculture provided more than $1 billion in FY2017 to be used to improve access to health care services for 2.5 million people in rural communities.
- The Trump administration expanded access to Association Health Plans (AHPs) allowing small business to pool risk across states.
- The Trump Administration allows for Short-Term Limited Duration plans to be extended up to 12 months.
- President Trump signed a six-year extension of the Children’s Health Insurance Program to fund healthcare for 9 million. Keeping CHIP is expected to save the Federal government about $6 billion dollars.
- President Trump has mobilized his entire administration to address drug addiction and opioid abuse by declaring the opioid crisis a nationwide public health emergency
- Trump created a bipartisan opioid commission that issued 56 recommendations to help defeat the opioid crisis
- In October 2017, President Trump directed The Department of Health and Human Services to declare the opioid crisis a public health emergency, allowing grant money to be used to combat abuse
- President Trump signed the International Narcotics Trafficking Emergency Response by Detecting Incoming Contraband with Technology (INTERDICT Act) that would give customs agents $9 million for screening tools on the border
- In FY2017, HHS invested nearly $900 million in opioid-specific funding
- Trump successfully pressured China to close dangerous loopholes that allowed Chines fentanyl manufacturers to legally ship the compound worldwide, much of which ended up in the U.S.
- Under President Trump, The FDA has approved the largest number of generic drugs in history.
- Generics increase competition in the marketplace and lower the cost of prescription drugs for all Americans.
- In December 2018, year-end drug prices fell for the first time in nearly 50 years.
- The Trump Administration issued guidance expanding options for individuals with chronic conditions. High deductible plans can now cover products such as insulin, inhalers and statins pre-deductible
- President Trump signed an executive order to modernize flu vaccines and help protect more Americans by promoting new technologies to improve vaccine manufacturing and effectiveness.
- Took executive action to strengthen Medicare and reform the Medicare program to stop hospitals from overcharging seniors on their drugs.
- The Departments of Labor, Treasury, and HHS issued a final regulation expanding the use of health reimbursement arrangements (HRAs) which will benefit more than 11 million people.
- Created new insurance options though association health plans, short-term plans, and health reimbursement arrangements: some are up to 60% less expensive
- HHS finalized a rule aimed at increasing transparency in the pharmaceutical industry that requires drug companies to disclose the price of medication in direct-to-consumer television advertisements.
- Launched initiative to end HIV/AIDS in America.
- Ensured Great Healthcare with initiatives to SAVE AMERICAN LIVES: $6 billion funded to fight the opioid, fentanyl, and drug addiction epidemic.
- HHS Awarded $125 Million In Grants to 1,352 Community Health Centers Across All U.S. States, Territories And The District Of Columbia.
- HHS Released A Tool For Medicare Consumers That Would Allow Them To Participate In Negotiating Lower Prescription Drug Prices.
- Under urging by the Trump Administration, Pfizer and Novartis have agreed to voluntarily drop their prescription drug prices.
- Passed Right-To-Try to give critically ill patients access to life-saving cures.
Actually, politicians are far more likely to cause damage than to fix things. Once again, the fact that exactly the same issues are put on the table in every single election in modern memory is evidence of that. They run the country. If they keep saying the same things are broken either they are incompetent, don't care or are only looking after themselves and their respective parties. In the meantime we sit in the middle and suffer the consequences.
So, yeah, I agree with you, Trump isn't responsible for the entirety of the economy improving and neither was Obama. A little, maybe, but not the bulk of it. I hate it when politicians take credit for what they did not do.
The vast majority of the people generally get the govt that they deserve, don't they? Not disagreeing with anything that you said. But I would be surprised if in a typical democracy people +elected smart, analytical upright people versus scam artists. One sees similar dynamics play out even in small groups so how are large groups like nations supposed to be immune?
+=Of course it is another subject if the elections are indeed 'fair' or rigged.
I agree.
Robomartin, mind contacting me? Email is on my profile. ( I could not see any contact information on your profile).
If you get really sick, "gotcha".
You mean hospital administration and private equity firms buying hospitals and squeezing them for all they can.
[1] https://www.who.int/gho/health_workforce/physicians_density/...
https://www.healthcare.gov/health-care-law-protections/lifet...
https://www.healthcare.gov/coverage/what-marketplace-plans-c...
If the plan qualifies for meeting the mandate, there shouldn't be maximums on essentials.
No, they are not. 401k is a protected asset, and is basically off limits to creditors. Similarly, it depends on the state, but most states provide for homestead protection from creditors. In some states, like Texas, the homestead protection amount is unlimited.
For instance, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5865642/ “ However, the magnitude of the bankruptcy effect is much smaller than previously thought: we estimate that hospitalizations cause only 4% of personal bankruptcies among nonelderly U.S. adults, which is an order of magnitude smaller than the previous estimates described above.”
I am an American in her 30s, on disability, who has Medicare. I am looking to return to the workforce, after I complete my final year of engineering school, in electrical engineering.
I require a blood product that costs $300,000/year in order to survive. I have 2 rare immune-mediated diseases that affect my peripheral nervous system, which are in pharmaceutical remission, thanks to this medicine. It is the only thing that has worked, and we have tried about 10 treatments, plus combinations of them. It is my only option.
In addition to having Medicare, I also have employer-based insurance through a family member. For reasons which I will not discuss, it is extremely likely that I will lose this coverage if the Affordable Care Act is partly or completely repealed.
I can expect to pay at least $50,000/year for this via Medicare coverage, if it is my only insurance, as I will be subjected to Part D catastrophic coverage levels. Obviously, I cannot afford to. One would be lucky to be able to afford this, even if they saved and were living on a huge pile of money, which is unlikely even working as an engineer.
Living in the US is just not worth it. You would be lucky not to need an exorbitantly expensive medication at some point in your life. Cancer meds are unbelievably expensive too. Almost half of cancer patients exhaust their lifetime savings within 2 years of diagnosis. 62% are in debt from it.
Besides stuff like that, in the US the third leading cause of death is preventable medical errors (if you do not believe me, Google it), which is on par with third world countries. You can go to the best institutions and get the best possible medical care, but I can assure you that you cannot evade that statistic, with it being #3 as the cause of death.
I want to work in the US but with my healthcare being so tied to my insurance, it really does not work for me.
This country is no place to live, if you want to survive your health problems. The best place to go, in general, if you are concerned about healthcare are the European Union countries. They do not discriminate on the basis of your health status, but you will have to work and earn your citizenship.
You can also get citizenship by descent. I naturalized as Croatian (also as an European Union citizen), as I cannot afford to risk my health here any more. My situation is more precarious than one would think.
Your 401k and retirement accounts ( pensions, IRAs, trust funds, etc ) are legally protected from bankruptcy or legal judgments. In some states ( like florida ), even your home is protected from bankruptcy or legal judgments. Otherwise OJ Simpson who be homeless begging on the street rather than playing golf every other day.
Medical issues can be a source of financial distress for sure, but your statement about 401k is simply not accurate.
Getting rid of insurance companies is only part of the equation, as far as I can tell. It could help quite a bit. But until we address the adversarial position that providers themselves take towards their patients, we're going to have galling and disgusting outcomes.
It is definitely the horse needed before the cart, and expecting a pharmaceutical/insurance funded government to pass the requisite regulations against its own interests would be cart first.
Unless of course, we could somehow acquire a government that acts on the interests of the people.
Apart from that, I wonder why the society in the USA is so adversarial. It is apparent in many aspects and it is damaging for the society. There are ways to reduce to adversity, but it seems that many people support and favour an adversial system. Is that a cultural curse of the USA?
It's been this way for a very long time, and it's only getting worse.
In a nutshell, there is no unified US society - Americans fear and hate their neighbor, which has resulted in societal dysfunction.
You probably don't really want to know how deep the ugliness goes, but here's several reported reasons:
- holdover from the first European settlers, the Puritans, where the word "puritanical" originated
- half the voters are often stereotyped as "people afraid of somebody else getting more." See Fox news.
- "Just society" belief (the poor or unfortunate must have deserved it)
- lack of homogeneity. See "salad bowl."
- mobile population causes isolation from families
- "at will"/feudal employment and ruthless healthcare system
- anti-intellectualism, with Trump as the poster boy
- tax policies designed to help the rich, and strip the middle class
- otherwise, lack of policies at all levels of US government
- rulers more concerned with controlling foreign countries than actually governing their own
- "anybody can be sued for anything"
- "I got mine." attitude
- rich people saying "I wouldn't mind paying more taxes, as long as I get to choose what it's spent on."
- in California, Prop 13 and 8% pensions starve school districts and social services with mathematical certainty
It's not unheard of for people who are lost using a door bell or driveway and getting shot to death. In other words, homeowners are sitting in the dark with loaded weapons, waiting to proudly kill anybody who passes by. See "castle doctrine."
It would take leadership to admit there's a problem and to steward policies rather than engage in empty rhetoric.
Instead we have special interests and lobbyists, and the invisible hand of the wealthy writing our laws and pulling the strings.
When you look at the existing divisions in American society, you can see how a few thousand "fake news" accounts could do a lot of damage to magnify those divisions.