Monday, July 22, 2024

Naturalized and adopted citizens and Medicare/Social Security - the SSN class trap and a likely SSA software process failure


  1. If you are a US citizen by naturalization or adoption you should check (call SSA and wait on phone for 1-2 hours) that your SSN is classified as US Citizen. The reclassification of an existing SSN has been an issue for over 40 years. If it is not correctly classified you will run into problems when you start Medicare or Social Security coverage (which can be at different times).
  2. I think the rats nest of issues I ran into getting Medicare coverage arose because SSA software automates routine processes but it doesn't cover this problem. AND there isn't an effective process to manage exceptions to the automation rules.


One of the joys of Oldness includes obligatory encounters with overwhelmed government services, not least the Social Security Administration. Recently I fought my way past the usual array of minor bugs and UI issues and browser incompatibilities to register for Medicare 8 weeks before my 65th birthday around May 30 2024.. I believe it was on the first day that I was eligible to start the process online.

That's where it went bad. After completing the application the screen briefly showed a confusing message about needing to submit some sort of additional documents -- but not which documents. I also got an email dated 6/3/24 saying to expect instructions. I waited ... and nothing happened. My online application status indicator stayed at the start of step II.

I checked the online status many times over the following weeks but nothing turned up. I finally phoned SSA and after about 1-2hours of waiting I got someone who started to work the problem. Somewhere during this process my line was disconnected. SSA staff don't have a way to call back or reach anyone who is disconnected.

After a week or two I were getting closer to my birthday and I forced myself to phone again. This time after 1-2 hours I was told to bring my naturalization certificate and state ID to our local SSA office.  I was later told this advice was wrong for my situation -- in fact they needed my passport and state ID. (I suspect two government approved IDs and my naturalization papers and birth certificate might have worked if I didn't have a passport.)

In the aftermath of the CrowdStrike fiasco I waited 3.5 hours in the local SSA office until I finally reached a very pleasant expert who looked at my passport and state ID, explained that my SSN classification was wrong, and passed on the correction to the one person who could process it. Somehow that happened the same day -- so I think she made an extra effort.

The SSN conversion thing is a problem -- two our children were born in Korea and both got caught out by this. SSA being overwhelmed is a problem too -- not everyone can spend hours and hours waiting on the phone or at the SSA office.

But the interesting problem to me is that I only received one of two emails that I was told were supposed to have been sent to me and neither of the two paper letters that were supposed to have been sent. In addition the description of the problem I saw in the original online submission form was incomplete and only showed there. 

I'm sure SSA believes I missed the 2nd email and that I threw out both SSA letters. The latter is especially unlikely; we have two special needs children and Emily does NOT miss SSA letters. It's a life, death, and taxes class thing.

That's what SSA would believe, but I think the letters were never mailed and the 2nd email was never generated. That what's would happen if the business logic in SSA automation didn't have a specific response to the SSN classification problem AND didn't have a good process for "problems not elsewhere classified". That would also explain the incomplete or misleading instructions my second phone rep passed on to me. It might even explain why the first phone rep might have dropped my call (lest she fall infinitely far behind).

I wasted a lot of hours dealing with this, and so did SSA staff. I worked for years with government software so I'm not optimistic this will get fixed; I suspect "edge cases" will be falling off the SSA process for decades to come. But I did write our state representative's office, so maybe the summer student will find a way to pass on the speculative bug report.

Thursday, July 11, 2024

The LLM service I will pay for -- call Social Security for me

One of the fun things that happens to Americans as we become redundant to life's requirements is signing up for Medicare. There's a sort-of-useful cobbled together web site to do this. Processing is supposed to take under 30 days, though I've read the federal mandate is 45 days. Perplexity basically says it's heading towards 60 days average.

Anyway, my wee application is well over the 30 day limit. There's no way to contact anyone other than the phone. Which my wife assures me takes at least 45 minutes on hold. (Don't fall for the "call back" and "hold your place in line option" -- my wife tells me they simply don't bother.)

And, yes, the hold music is horrendous. As Emily says: "One of the challenges of getting old is listening to music on hold. No one ever tells us."

So, while I wait on hold I once again think how there's one LLM service I want to pay for. Want.

I want to give my Agent the social security and medicare data it is likely to such; case number, my SSN, my phone, etc.  I want it to call social security using my voice and sit on hold for days, weeks, years until someone accidentally answers. Then it begins the conversation while paging me to swap in .... with a text summary of current discussion and a timer to join in 5.... 4..... 3.... 2.... 1....

Yeah, that would be worth some money.

Update 7/19/2024: I finally got through to be told that requests were mailed to me 6/3 and 7/3 requesting additional information. We are very vigilant about social security correspondence so it's very unlikely they were delivered here. We have seen MN Post Offices lose tracked social security correspondence, presumably due to internal theft.

Monday, July 08, 2024

Cannondale Scalpel Team Carbon 2010 XC 26" wheel bike with Lefty Speed Carbon SL and Mavic Crossmax Axle cap is part number KH124 (maybe)

Twenty years go when I wrote a post title like this one I was pretty sure at least one person who needed help would find through Google and have a better day.

Now? It's like tossing a bottle in the ocean.

If you happen to have come across this bottle here's what you need to know about this weird bike that I picked used when I didn't know any better and have an odd affection for. Even though it's the bike equivalent of a 20yo Porsche -- albeit with much better engineering than a Porsche.

  1. If you have a Cannondale dealer or good local bike shop just use them.
  2. The Cannondale Lefty suspension is a cult within the XC singletrack world and Cannondale did whatever weird/fun thing came to mind.
  3. With this single (Left!) side suspension comes a proprietary hub that has been through at least 3 revisions. The version I have is forgotten by most (Cannondale very kindly sent me a free replacement when I asked -- but it was the wrong version!) The weird hub has a proprietary hub retention system made up of a fancy bolt with rubber O-ring that does most of the work along with a reverse threaded "axle cap" that engages with the O-ring, keeps water and dirt out of the moving parts, and also helps with bolt retention (bolt loosens but runs into the reverse threaded cap and they kind of jam together). Cannondale tweaked this design often because that's what they do (and why some love them and some fear them). Some models tightened with a Shimano freewheel tool, others used a pin-type chainring tool (but at least they aren't super exotic tools).
  4. These caps tend need replacing. Probably because most don't expect the reverse threading and strip it the first time they change a tire. Or they fall off.
  5. My 2010 Lefty Crossmax hub uses the Cannondale Lefty SuperMax Axle Cap and Bolt - Black - KH124. After my model came the Lefty 50 Hub Axle Cap And Bolt - Black - QC117. This 50mm standard width part is much too shallow for my bike, even though it's described as  fitting "vintage Lefty hubs, Lefty SL hubs, and Lefty 50 hubs including Lefty Oliver. Will not correctly fit SuperMax, Lefty 2.0, Lefty 60, or Lefty Olaf hubs."
  6. There are other versions I think for later boost and fat bike hubs.
UPDATE 7/12/2024: It fits better than the QC117 but it screws deeply into the hub and might kind of float in there? Sort of weird.

Monday, July 01, 2024

Gabapentin, Alzheimer's, fake science, and the National Library of Medicine

Gabapentin was developed as a focal seizure medication and has been found to be effective for neuropathic pain syndromes in diabetic neuropathy and postherpetic neuralgia.

Gabapentin is also widely used in America for a variety of pain syndromes including sciatica. The well done wikipedia article has a good overview of what we know about these uses. In general the benefits of gabapentin for many pain syndromes are not clear; as usual more research is needed. The evidence for nerve healing benefit is weak. I am confident we would almost never use gabapentin for chronic sciatic pain if opioids were not cursed by tolerance, dependence, dosage escalation, respiratory suppression, and diversion to recreational use. Without opioids we have acetominophen and ibuprofen and not much else.

In addition to doubts about efficacy some patients report significant persistent side-effects of somnolence and fatigue, sleep disruption, and a withdrawal syndrome that resembles benzodiazepine withdrawal. In my own life I've taken gabapentin for months for spinal stenosis* and I have not experienced either obvious benefits or problems, but I believe reports that some people have unpleasant withdrawal syndromes.

The combination of unclear benefit outside of diabetic neuropathy and idiosyncratic withdrawal syndromes would be enough to make gabapentin unpopular. Beyond that there's a significant group of chronic pain patients who feel they would do much better on opioids; they believe they are getting a defective substitute because of an excessive reaction to physician overuse of opioids in the 1990s. It's easy to see why gabapentin is not loved.

Which brings me to the point of this post. I have seen claims from the community of chronic pain patients who have legitimate suspicion about the value of gabapentin that "gabapentin causes Alzheimer's" based on an article published out of TaiwanThe association between Gabapentin or Pregabalin use and the risk of dementia: an analysis of the National Health Insurance Research Database in Taiwan. The authors conclude "Patients treated with gabapentin or pregabalin had an increased risk of dementia. Therefore, these drugs should be used with caution, particularly in susceptible individuals".

Long ago I was an academic family physician who did the tedious work of evaluating research publications. Back then I'd have had to point out that this is an outrageous conclusion to draw from data mining a health insurance data set. If all the right boxes were checked and procedures followed the most one could conclude from this type of study is that maybe there's some signal that should be researched in animal models and maybe one day in a range of increasingly expensive and complex studies. In those days that conclusion in an abstract would be the end of my interest in the publication.

Sadly, these days, we don't even have to look that deeply. We start with looking at where an article was published. Front Pharmacol is a pay-to-publish eJournal. That's why you can read their articles without paying - the authors paid for you to read it.

You can find the publishers of this article in and read about them in a wikipedia article on Frontiers Media. Nobody, absolutely nobody, would publish in Frontiers if they could get through peer review anywhere else. Derek Lowe is the most publicly accessible writer about this class of publication, you can read two of his recent pieces here and here. The garbage output of these fake journals to qualify for academic promotion is so bad that even PRC academic centers are turning against them: "... January 2023, Zhejiang Gongshang University (浙江工商大学) in Hangzhou, China, announced it would no longer include articles published in Hindawi, MDPI, and Frontiers journals when evaluating researcher performance."

In short, in our broken modern world, we don't have to dig into the particulars of this article. We don't have to even look at the absurd abstract conclusion. All we have to know is that the authors of this article paid to get it published by an enterprise that is almost certainly fraudulent.

It's not impossible that any substance that interacts with the human body might in some way increase the risks of Alzheimer's dementia. That, I suppose, includes cosmic rays. But there's no particular reason to suspect gabapentin more than other medications. This is a bullshit result published in a bullshit journal.

So why, a reasonable person would say, was this crap indexed by the National Library of Medicine, a division of the National Institute of Health funded by the American tax payer? That's a damned good question. I can guess why the NLM is effectively promoting fraud, and I can suggest workarounds for the problems I'm guessing they have, but I honestly don't know. I am, however, angry. As you might guess. I'm sick of this academic fraud.

* I'm now post-decompression surgery. That's a story for another day.