The US health department on Friday declared a public health emergency for California in response to devastating wildfires in the Los Angeles area that have so far killed 10 people and destroyed more than 10,000 structures.

As of Friday morning, 153,000 residents are under evacuation orders, and an additional 166,800 are under evacuation warnings, according to local reports.

Wildfires pose numerous health risks, including exposure to extreme heat, burns, harmful air pollution, and emotional distress.

Read full article

Comments

• More than 3,600 older Americans have shared their financial and other regrets with Business Insider.
• Many said they regretted relying on government programs designed to keep them out of poverty.
• This is part of an ongoing series about older Americans' regrets.

America is getting older — and that shift is straining the federal programs meant to keep older people out of poverty.

Since mid-September, more than 3,600 older adults have shared their life regrets with Business Insider through reader surveys and direct emails. Many spoke about their struggles navigating programs like Social Security, the Supplemental Nutrition Assistance Program, and Medicare. This is part of a series on Americans' retirement regrets.

The overwhelming message was that these programs weren't enough to pay the bills. Retirees said they regretted not realizing this and not saving more to supplement their government checks.

BI followed up with several retirees and asked experts about the programs' performance and improvements they might need. Since most of the retirees rely on programs run by the federal government, the solutions discussed here mainly focus on the public sector. Others may have ideas for private or charitable solutions as well.

To be sure, many American retirees are doing just fine. Baby boomers have benefited from rising home and stock-market values over their lifetimes, and OECD data suggests the US's retirement system is doing well in some areas compared with those of other developed countries. Census data indicates roughly 11% of people 65 and older in the US lived in poverty in 2023, down from about 25% in 1976.

Still, many people are struggling, and the pressures are only likely to grow as the population ages and funding wanes. Some argue that such trends increase the need to preserve or bolster government programs designed to reduce poverty among older adults.

We want to hear from you. Are you an older American with any life regrets you'd be comfortable sharing with a reporter? Please fill out this quick form.

Americans increasingly rely on government checks like Social Security, and the program's funds are diminishing

Pamela Shields, 67, gets $1,470 a month in Social Security payments and an additional $600 from her jobs as a caregiver and a night-shift worker at her local grocery store. She had a long career in customer service and human resources, but she's dealt with unexpected medical expenses and two divorces, and she still provides her children with some financial support.

She said that Social Security wasn't enough to rely solely on and that she feared she wouldn't have enough to retire.

As with all beneficiaries, Shields' Social Security check amount is based on her earnings during her working years. But some major categories of spending — like housing, healthcare, and some utilities — have outpaced inflation in recent decades.

"I really want to be retired and not have to do all this stuff to make a living," Shields said. "But I don't see myself doing that."

Research from the bipartisan public-policy firm Economic Innovation Group suggests that US households like Wood's are increasingly reliant on government assistance like Social Security. EIG found that in 2022, Americans got an average of $11,500 in government payouts, representing 18% of the population's total personal income.

But Social Security may be in trouble, with payouts expected to start shrinking in the mid-2030s. As more baby boomers reach peak retirement age, the strain is expected to grow. Without a solution, they could be the last generation to receive full benefits.

"Social Security has been a very expensive program for a very long time, and it's more expensive particularly as we see upswells in the over-65 share of the population," said Benjamin Glasner, an economist at EIG.

One solution to extend the program's life is to start cutting benefits now. The US Government Accountability Office said in a report this summer that applying an across-the-board cut for all Social Security beneficiaries or cutting some spousal or widower benefits could increase longevity.

Of course, that would put people who are already struggling in an even tighter spot. Ultimately, Glasner said, the US needs more younger workers contributing to the Social Security fund through taxes. He argued that the US should invest more in helping people start and sustain families — the US's fertility rate hit a historic low this year.

"We will not be able to tax or cut our way out of this budgetary mess," he said. He also proposed consolidating various federal benefit programs, including Social Security, to reduce the administrative burden and reduce costs.

Another option is to turn up the nozzle on the program's funding sources: payroll taxes, interest on government securities, and taxes on benefits. Some Democrats, led by Sens. Bernie Sanders and Elizabeth Warren, have proposed raising payroll taxes on higher earners to help offset the cost of hiking benefits for everyone.

Gopi Shah Goda, the director of the Retirement Security Project at the center-left think tank Brookings Institution, said the US could consider how other countries address retirement programs, including using general tax revenue, like Australia, and focusing expenditures more on lower-income retirees, like Canada.

Because Social Security is among the federal government's biggest expenditures, some legislators are looking for cost-cutting strategies. House Republicans have proposed raising the age at which Americans become eligible for benefits. President-elect Donald Trump has suggested cutting Social Security income taxes for retirees, which could provide immediate relief but further imperil future funding for the program by reducing tax revenue overall.

Andrew Biggs, a senior fellow at the right-leaning American Enterprise Institute, has proposed capping monthly benefits at $2,050 beginning in 2033, arguing that this amount would keep more older Americans above the poverty line and keep benefits higher for longer than across-the-board cuts would when funding runs dry. This might mean smaller checks for higher earners, but he argued that Social Security is often inefficient for middle- and higher-income Americans because the safety net discourages them from working longer or saving more.

"Because of the taxes charged to fund those benefits, people tend to reduce their labor supply," Biggs said. "If I'm getting an extra $500 per month from Social Security, that's going to reduce the amount I save for retirement."

One way to help workers save more and extend the life of Social Security would be to increase access to employer-match 401(k)s at work. In a December fact sheet, AARP cited an estimate that 56 million Americans — the vast majority of whom earned less than $50,000 — lacked access to retirement savings plans through their employer.

A handful of BI's survey respondents mentioned wishing they had 401(k) matching at work or jobs that provided financial guidance for retirement.

Still, retirees' average Social Security benefits are over 40% higher than they were in the 1970s when accounting for inflation. Participation in — and contributions to — retirement plans has increased since the 1970s. People are also claiming Social Security slightly later in life.

Researchers said that delaying taking Social Security could substantially improve people's retirement security, provided they have other income sources.

Some Medicare and private insurance plans hike premiums on older people or don't cover some needs

Older Americans told BI that medical emergencies, the need for long-term care, or expensive prescriptions eroded their savings. Whether they have private or government insurance, out-of-pocket costs add up. For those on a budget, affording healthcare and other essentials can be challenging, especially if medical conditions keep them from working.

Ronda Nichols, 60, worked as a paralegal, but her career ended when she slipped on ice in 2008. Her emergency savings weren't enough to cover her surgery, which, with aftercare costs, cost well into the hundreds of thousands of dollars. Nichols, whose Medicare premium is paid for by Idaho, lives on about $1,100 in disability and $300 from her late husband's pension each month, much of which goes toward prescriptions and over-the-counter pain medications.

"Economically this injury has really impacted me, because every month I think if my Social Security doesn't come I'm screwed," Nichols said.

About 68 million people are enrolled in Medicare, which is divided into traditional Medicare and private insurance overseen by Medicare, such as Medicare Advantage plans.

Dr. Joel Shalowitz, a specialist in geriatric medicine who formerly taught at Northwestern University, said older people could save money on health-insurance premiums if private policies and Medicare Advantage health plans were forbidden from steeply hiking rates for older beneficiaries, as some policies on the Affordable Care Act Marketplace are.

Plus, he said, if all Medicare plans offered health savings accounts, older adults could build emergency funds for medical expenses and out-of-pocket costs.

Goda said many older Americans aren't aware that some Medicare plans don't cover long-term care, hearing aids, or dental care. "It's in a way impossible to know every possible outcome of what ailment you might have and how your health insurance will cover the resulting costs associated with that," Goda said.

She suggested that streamlining access to benefits and subsidizing services for people who need long-term care could improve the system. Goda added that an aging population doesn't always correspond to increased dependency. She argued that the US should invest in health throughout people's lives, citing research that childhood Medicaid eligibility for young people with disabilities was associated with higher employment and lower transfer-program costs decades later.

In a 2023 article, David Henderson, a research fellow at the right-leaning Hoover Institution, said that if Medicare cuts were to happen, Americans might value turning the program into a per capita benefit where each person receives a set amount to spend as they see fit and particularly sick people get double the allocation.

"Spending $900 billion on 65 million people would give each person $13,800," Henderson wrote. "The vast majority of people would value this $13,800 much more than they would value the amount that Medicare spent on their health care."

An outdated poverty line is preventing some older Americans from getting help

The poverty line, set at $15,060 annually for a single person, has been calculated nearly the same way since the 1960s, when housing was cheaper and groceries were a larger component of household budgets. Many government-assistance programs, like SNAP or Medicaid, base their eligibility criteria on this measure.

Older Americans told BI these programs didn't always provide enough aid to pay their bills. Mary and Steve Dacus, both in their late 60s in Robinson, Illinois, receive $23 in SNAP benefits and $2,140 in Social Security income a month. Mary previously told BI that she and her husband felt food insecure, and she called their limited SNAP allotment "pitiful."

Americans over 65 account for the largest increase in households classified as ALICE: asset-limited, income-constrained, employed. These Americans are still working and make too much to qualify for most government benefits but not enough to cover all their bills. Stephanie Hoopes, the national director of United For ALICE, said that removing complicated paperwork and verification steps could streamline applications for aid programs.

She said that raising the federal poverty threshold and expanding eligibility for government-assistance programs could also help many people access essentials. Of course, any safety-net expansion would have to be paid for by higher taxes or changes in state and federal budgets.

Hoopes added that benefits could be adjusted based on how inflation affects the costs of housing, childcare, food, transportation, healthcare, and technology, adding that this "would allow participants to keep up with the cost of their basic needs."

Still, changing the poverty line would most likely mean that government-assistance programs like SNAP would need more funding to operate, and it would increase the number of Americans considered to be in poverty — a politically unpopular move.

Are you an older American with any life regrets you'd be comfortable sharing with a reporter? Please fill out this quick form.

• The government lost billions of dollars to fraud and improper payments last year.
• Both Musk and Ramaswamy have indicated they'll crack down on fraud through DOGE.
• Some experts told BI they're optimistic about action on fraud, but the DOGE leaders have to be willing to invest in the issue.

Elon Musk and Vivek Ramaswamy have an opportunity to take on fraud in government programs once President-elect Donald Trump takes office.

Musk and Ramaswamy are tasked with leading the new Department of Government Efficiency, or DOGE, which seeks to reduce government waste and slash spending. Musk set a goal of cutting $2 trillion in annual outlays.

One of Musk and Ramaswamy's aims for DOGE could lead to a relatively early win with bipartisan support: eliminating fraud in federal programs like Medicare. In a recent interview, Ramaswamy told CNBC that "the dirty little secret is that many of those entitlement dollars aren't even going to people who they were supposed to be going to in the first place."

"There are hundreds of billions of dollars of savings to extract" through basic fraud prevention measures, he said.

Musk shared that sentiment, posting on X in November: "The sheer magnitude & audacity of government fraud is mind-blowing!"

Data from the Government Accountability Office showed that government agencies have made about $2.7 trillion in improper payments since 2003, and in fiscal year 2023, the GAO estimated agencies made $236 billion in improper payments. Notably, those improper payments include other categories than intentional fraud, like administrative errors, Orice Williams Brown, the GAO's chief operating officer, said in a September testimony to Congress.

"While all fraudulent payments are considered improper, not all improper payments are due to fraud," Brown said.

The top impacted agencies were Medicare and Medicaid, which the GAO said had $51 billion and $50 billion in improper payments, respectively, followed by pandemic programs, including the Paycheck Protection Program.

Experts told Business Insider that there's potential for DOGE to make progress on the issue if they focus on effective solutions like system modernization and improved data analysis, an area where Ramaswamy and Musk could leverage their Silicon Valley tech experience.

Both fraud and improper payments have been difficult for the government to address because of "outdated technology and a limited focus on program integrity," Linda Miller, cofounder of the Program Integrity Alliance — a group that focuses on fraud prevention in the government — told BI.

"You need to use advanced technology and data in order to really move the needle," Miller said. "And the government is not using advanced technology and data to solve this problem."

Jetson Leder-Luis, an assistant professor at Boston University and researcher on government fraud, told BI that DOGE could pursue "a lot of low-hanging fruit ideas" to combat fraud in big industries like healthcare.

"I think DOGE has the opportunity to make big strides on fraud," Leder-Luis said, adding that if they boost enforcement funding and create enhanced data pipelines, "they have a major opportunity to save tens of billions of dollars."

The Trump transition team did not immediately respond to a request for comment from BI.

How government programs make way for fraud

The government has been unable to implement widescale fraud intervention in recent decades because of a lack of resources and staff to investigate fraud, and a failure to modernize data and technology systems, according to Miller and Leder-Luis.

The GAO found that the government's annual financial losses from fraud were between $233 billion and $521 billion, based on data from fiscal years 2018 through 2022.

Miller pointed to the pandemic as the "perfect storm" for fraud, with the Paycheck Protection Program and disaster loan programs as key examples. Miller said that all that aid being available, coupled with limited oversight at the government level during a national emergency, made it easier for fraud to go undetected; some of the programs allowed individuals to self-certify their loan applications, paving the way for misrepresentations.

"The lack of modernization of our digital technology at the state government level was a real hindrance to fraud prevention during the pandemic," Leder-Luis said.

There have been a number of instances where individuals attempt, and sometimes succeed, to game the system and score welfare benefits that they're not entitled to. But, Miller said, the bigger concern is beyond the individual circumstances; it's the "large-scale fraud schemes" that have taken millions of dollars from the government. For example, the FBI opened an investigation into a scheme that Medicare officials said defrauded the program out of $3 billion after some companies billed the program for catheters patients never requested or used.

Lawmakers and the Department of Justice have worked to take action over the past years to address fraud, including with the federal Pandemic Response Accountability Committee that oversaw pandemic-era programs. Still, Miller said that while agencies are focused on getting benefits to the beneficiary, there still isn't enough attention on ensuring benefits are going to the right person.

"That's the kind of thing that I think really angers Americans," Miller said. "You wonder, 'What are your tax dollars going to if they're not stopping that kind of fraud?'"

Where DOGE can play a role

Miller said she expects DOGE to look for "quick wins" soon after Trump takes office. These could include modernizing IT systems and investing more resources into fraud detection. A critical point DOGE will have to contend with is that cracking down on the cost of fraud would require some upfront investments.

"It can be very helpful to have a private sector lens come in and look at this," Miller said, which is why Musk and Ramaswamy's backgrounds could be useful in introducing new technology to government systems. However, she said, the two DOGE leaders have to be willing to invest in new fraud detection systems because, even amid their goals to slash spending, modernizing technology is not going to be free.

The GAO's Brown also outlined recommendations for federal agencies to better prevent fraud, including using external data from third parties to verify information Americans provide on loan and insurance applications.

With Republicans soon holding control of both Congress and the White House, DOGE's recommendations to Trump and lawmakers would likely see an easier path to passage. Addressing fraud has also seen Democratic support; Rep. Jamie Raskin introduced the Government Spending Oversight Committee Act in April, which would give federal inspectors general tools to combat fraud across major funding bills.

To be sure, some lawmakers and experts are skeptical of DOGE's approach. The US spent $6.75 trillion in fiscal year 2024, data from the Treasury Department showed, and it wouldn't be as simple as the DOGE leaders have said to ax that spending, lawyers told BI.

While administrative law requires a lengthy process to rescind regulations in federal agencies, Musk and Ramaswamy previously said they would recommend a list of regulations that Trump could "immediately pause." Some lawyers previously said the process is a lot more complicated, and the DOGE leaders would likely face legal hurdles if they pursued that route.

Musk and Ramaswamy also aren't the first to suggest cuts to government spending. Former President Ronald Reagan's Grace Commission, aimed at eliminating waste and inefficiency in the federal government, eliminated $22 billion in social welfare programs that ended up being offset by his tax cuts and defense spending.

Still, Leder-Luis said, what DOGE determines as "waste" is up for interpretation, whereas fraud is illegal, and there's support across the aisle to take that on.

"If we lose $50 billion a year to fraud in just the healthcare system alone, that's ultimately paid for by us," Leder-Luis said. "There are so many things that people want the government to be able to pay for that we all think are good and valuable, like better roads and schools. And when we say, 'I'm sorry, we can't afford that,' well, we are affording healthcare fraud instead."

• Donald Trump will decide whether to renew subsidies that make the ACA marketplaces more affordable.
• Biden's enhanced ACA subsidies, which lowered premiums for the middle class, will expire in 2025.
• Ending the subsidies would save the government money, but increase premiums for many Americans.

Federal subsidies meant to make health insurance more affordable for low- and middle-income Americans could be on the chopping block when Donald Trump returns to the White House.

President Joe Biden's enhanced version of the Affordable Care Act subsidies — which provide lower premiums and reduced out-of-pocket costs for lower-earning Americans who don't get health insurance subsidized by their employer or a government program like Medicaid — are set to expire at the end of 2025. At some point next year, Trump and a Republican-led Congress will decide whether to renew or end the subsidies.

Ending the subsidies would save the government money but restrict healthcare options for the people and families who rely on them. If the subsidies are allowed to expire, the Congressional Budget Office estimated that nearly 4 million people would drop coverage in 2026. 

The president-elect has been inconsistent with his support for the Affordable Care Act and has previously proposed cuts to healthcare programs like Medicare and Medicaid. The Trump transition team did not respond to BI's inquiry about ACA subsidies but previously shared a statement that Trump would "protect Medicare" as president.

Trump has not publicly said whether he plans to let the enhanced ACA subsidies expire, but he has made cost-cutting a cornerstone of his second-term promises.

The Affordable Care Act — also known as Obamacare — was passed in 2010. The law introduced the ACA marketplaces, which were meant to make health insurance more affordable for lower-earning people whose incomes would be too high to qualify for Medicare and Medicaid. It also requires insurance companies to cover preexisting conditions, like diabetes and heart disease.

Biden's expansion increased the financial assistance for people already on ACA plans and lifted the income eligibility cap for those benefits. Some middle-class families had previously been priced out of health insurance.

Since 2020 — the year before the subsidies went into effect — the number of people with ACA marketplace coverage has grown by 88%, to 21.4 million people from 11.4 million, per KFF.

Gary Young, the director of Northeastern University's Center for Health Policy and Healthcare Research, told Business Insider that the ACA subsidy debate underlines a growing problem: America's healthcare costs are ballooning, and it's taking a toll on people's finances and federal budgets.

"We are having this debate at the same time that we are beginning to see healthcare costs ramp up," Young said.

How ending ACA subsidies would impact Americans and government spending

Ending subsidies would be cheaper for the government and taxpayers. Some Republicans like Vice President-elect JD Vance have said they want to inject needed competition into the health insurance marketplace. Young said a more robust marketplace could lead to more diverse insurance plans being available, allowing people to choose coverage that best fits their needs without the government footing the bill.

"There's concerns about whether the subsidies maybe went too far," Young said. "They're providing people with financial resources to purchase more extensive insurance than they otherwise would purchase, and it's not necessarily an efficient way of using federal resources."

Still, Young said letting the ACA subsidies expire would probably make healthcare more expensive for millions of people. Nearly all Americans on ACA plans would pay higher premiums, he said. KFF reported that low-income people would see the steepest increase in healthcare costs relative to their income.

Any move by Trump to change ACA policies would need congressional approval. Because insurers have to submit their plan proposals next summer for the 2026 enrollment period, Trump will probably need to decide early in his term whether to extend the enhanced ACA subsidy.

Trump's 2nd term has a cost-cutting agenda

The US government spent $6.75 trillion total in fiscal year 2024, which resulted in a national deficit. At $912 billion, the Department of Treasury reported that healthcare — programs like Medicaid, the Children's Health Insurance Program, the Centers for Disease Control and Prevention, and more — is a top government expenditure behind Social Security. Medicare costs add another $874 billion. If the enhanced ACA subsidies were to become permanent, the Congressional Budget Office and Joint Committee on Taxation estimate that it would cost $335 billion over the next 10 years.

Tesla CEO Elon Musk and former GOP presidential candidate Vivek Ramaswamy were tapped by Trump to co-lead a new Department of Government Efficiency. The pair plans to propose cuts for the government's most costly programs, but it's not yet clear if that will include healthcare programs.

Trump's nominees for the top healthcare positions are Robert F. Kennedy Jr. leading the Department of Health and Human Services and Dr. Mehmet Oz leading the Centers for Medicare and Medicaid Services. Neither Kennedy nor Oz has outlined a specific plan for affordable healthcare in 2025, and neither responded to a request for comment.

In an opinion piece published in 2020 on Forbes, Oz said he supports a universal healthcare plan, but the stance is likely to be at odds with the Trump administration's cost-cutting agenda.

Are you doing anything to prepare your finances or healthcare plan for Trump's second term? If so, please reach out to this reporter at [email protected].

Correction: December 2, 2024 — An earlier version of this story misstated who is eligible for the enhanced Affordable Care Act subsidies. The subsidies apply mostly to people who purchase health insurance on the Affordable Care Act marketplaces. Some Medicare recipients are also eligible, but not Medicaid recipients.

• President-elect Trump has tapped Dr. Mehmet Oz, tv celebrity and surgeon, to run the agency.
• Trump said Oz will "cut waste and fraud" in the agency that oversees Medicare and Medicaid.
• Oz ran for Senate in 2022 and does not have experience leading a large government bureaucracy.

President-elect Donald Trump has named Mehmet Oz, a television personality and surgeon, to run the Centers for Medicare and Medicaid.

"He will also cut waste and fraud within our Country's most expensive Government Agency, which is a third of our Nation's Healthcare spend, and a quarter of our entire National Budget," Trump said in a statement announcing the pick on Tuesday.

Trump said that in his role, Oz will work closely with Robert F. Kennedy Jr., whom the president-elect has chosen to lead the Department of Health and Human Services.

Oz unsuccessfully ran for a Pennsylvania Senate seat in 2022 but has no experience leading a large government bureaucracy. The CMS oversees Medicare and Medicaid, among other services.

Dr. Oz demonstrated broad appeal as a TV host

As a cardiothoracic surgeon, Oz gained prominence with prestigious research awards and multiple patents for surgical methods and devices related to heart transplants.

Oz catapulted to fame in 2009, first as an expert voice on Oprah Winfrey's show "Oprah," then as the host of his own Emmy Award-winning "The Dr. Oz Show."

Oz captured millions of viewers with a variety of segments.

He hosted the then-First Lady Michelle Obama in one segment — they learned dances and spoke about her efforts to get America moving — and students of Sandy Hook Elementary School in another.

He also spoke about chemicals in food and natural methods to lose weight and whiten teeth.

Shortly before his show went on air, and became an instant success, Esquire named Oz "the most accomplished and influential celebrity doctor in history."

He has faced criticism in healthcare

Oz has previously come under scrutiny for some of the advice on his TV show, including weight loss supplements and diet plans.

His statements about garcinia cambogia, a supplement derived from the rind of a tropical fruit, led a class action lawsuit alleging that Oz misrepresented the products as a "revolutionary fat busters" and "miracles in a bottle." The suit resulted in a $5.25 million settlement.

Oz attracted a backlash from medical professionals during the height of the COVID-19 pandemic when he appeared to suggest that re-opening schools might be "worth the trade-off" if it increased mortality by 2-3%, or a few thousand deaths according to one estimate. He later walked back the comments, saying he misspoke.

Also during 2020, Oz promoted the anti-malaria medicine hydroxychloroquine as a treatment for COVID-19, attracting the attention of then-President Trump. Studies at the time the drug was effective in coronavirus patients.

Oz continued encouraging the White House to push the treatment. Financial disclosures later showed he had a financial stake in two companies that supply hydroxychloroquine (worth at least $615,000 in one company and between $15,001 and $50,000 in the other, according to the disclosures).

During his Senate run in 2022 against stroke survivor John Fetterman, Oz said his opponent would never have had a stroke had he "ever eaten a vegetable in his life," prompting more than 100 doctors to organize against his political campaign.

Columbia University, where Oz previously served as a vice chair of surgery among other roles, removed him from its website and cut ties in 2022.