No end in sight for rising health care costs

Written by: Joe F on Jun 23, 2009 4:44 PM EDT

By Joe Frandino

As health care and health insurance prices continue to grow more and more unaffordable to the average American family, many are nervous that there is literally no end in sight in terms of how high prices may go.

 Various reports by Health Care for America Now show that while health insurance coverage continues to shrink, the actual price of health care continues to rise across the board.  American families are paying more and more for health care and health insurance, yet the amount of medical services covered by their insurance companies continues to decrease.

By 2016, the increase in the cost of health insurance as a share of the median income will increase by 115% or higher in some states.  Do you think your family income is safe?  Check out this interactive map to see how your state will fair.

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Late night Watercooler

Written by: DFA Community and you

DFA's home for a free form, open-ended discussion of what matters most to committed progressive activists.

Last Week's D.C. Rally

Written by: Joe F on Jun 29, 2009 1:41 PM EDT

Check out this video from last week's rally in D.C.

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Health Care Costs & the Entitlement Crisis

Written by: SteveG on Jun 29, 2009 9:57 AM EDT

Linked to groups: Healthcare Advisors' Blog

In their 2006 book Aging Nation, Jim Schulz and Robert Binstock referred to "merchants of doom"--academics, political figures, and journalists who mistakenly believe that we cannot afford the aging of the population. A central concern of these doomsayers is the cost of entitlements, i.e., Social Security and Medicare, which they argue will "require massive tax increases, cause immense deficits or crowd out other important government programs".

Talk of a general entitlement crisis is misleading, however, because Social Security and Medicare face very different problems. According to the best estimate of the Social Security and Medicare Trustees, the Social Security Trust Fund will remain solvent until 2037, and between now and 2050, spending for Social Security will increase from 5 percent of GDP to 6 percent. This is an issue, but a relatively manageable one.

In contrast, Medicare's Hospital Insurance Trust Fund will run out in 2017, and, at current rates of spending, total Medicare spending will "grow from 2.7 percent of GDP in 2007 to 8.4 percent in 2050" (http://tinyurl.com/danjjd). Between now and 2050, spending per person on Medicare and Medicaid will increase from 5 percent of GDP to 20 percent. The entitlement problem is actually a Medicare (and Medicaid) problem.

It would be a mistake to assume that costs are an issue only for Medicare. Between 1970 and 2006, Medicare had a slightly better record controlling cost than private insurers. The underlying problem is health care inflation. According to Peter Orszag, Director of the Office of Management and Budget, "Health costs are the real deficit threat." To address Medicare, and provide affordable health care for everyone, we must succeed in "bending the curve," i.e. flattening out the growth of health care costs.

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Healthcare Reform with Sound Information Technology

Written by: Ge Z on Jun 22, 2009 10:16 AM EDT

Linked to groups: Healthcare Advisors' Blog

The substantive debate on the healthcare reform is in full swing and one of the center themes is the public option. President Obama wrote recently, "I strongly believe that Americans should have the choice of a public health insurance option operating alongside private plans. This will give them a better range of choices, make the health care market more competitive, and keep insurance companies honest." The latest NBC/Wall Street Journal poll shows strong, 76%, public support for public option (1). This is about essential choices and competition for accessible, affordable, and quality care; this is also about improving transparency, efficiency, value, and outcome. As a crucial component of the ongoing reform, sound Healthcare Information Technology (HIT) can be instrumental in realizing these objectives in a timely manner as the new healthcare system is been defined and will soon be implemented.

The new national healthcare system with the public option will facilitate the coordination and standardization of HIT, clear lacking of which at the present is delaying and denying the broader benefits of myriad of well established information technologies from the majority of payers, doctors and patients alike. Among the exciting new derived capabilities, HIT will become interoperable, and serve as the platform for reliable comparative effectiveness study to lower cost and achieve better outcome, much more effective than relying on the existing dysfunctional silo based approaches.

Today, any patient who seeks a second opinion, or moves from one city to another, often must request, pay, and carry his or her medical history and diagnostic images along. Another huge waste in healthcare expense today is redundant tests due to lack of ability to record, store, transfer, and compare previous obtained results promptly and safely. Without precedence, the recently enacted economic stimulus bill has committed a total of $19 billion to promote the adoption and use of HIT and especially electronic health record (EHR) by all doctors and patients across this country by 2014. The potential to promote prevention, reduce medical errors and health disparities, cut overall costs, improve and advance the delivery of patient-centered medical care is enormous.

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Senator Conrad’s Co-Op Option vs. the Public Plan Option

Written by: LindaB on Jun 15, 2009 11:21 AM EDT

Linked to groups: Healthcare Advisors' Blog

By now, Senator Conrad's "co-op" option has gained enough steam to generate a lot of heat, but not a lot of light in Congress. We do not know much about the option yet, and the reasons for its introduction are only now becoming clear.  In an interview with Ezra Klein of the Washington Post, Conrad attempts to describe his option and explain why it is necessary.

First, why is it necessary?

Senator Conrad: Maybe it would be most useful to tell you how I got into this. The G-11 group, which is the members of the Senate, Republicans and Democrats, chairmen and ranking members of the key committees, who've been given the overall responsibility to coordinate health care reform in the Senate, asked me 10 days ago to come up with something to bridge the divide between those who are strong adherents to the public plan and those who are strongly opposed.

The co-op structure came to mind because it seems to fulfill at least some of the desires of both sides. In terms of those who want a public option because they hope to have a competitive delivery model able to take on the private insurance companies, a co-op model has attraction.

And for those against a public option because they fear government control, the co-op structure has some appeal because its not government control. It's membership control, and membership ownership. Also the co-op model has proven very effective across many different models. Ocean Spray in the cranberry business, and Land of Lakes in the dairy business, and Puget Sound in the health care business.

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Healthcare is a Right and it is Time for Action

Written by: Enku K on Jun 8, 2009 10:05 AM EDT

Linked to groups: Healthcare Advisors' Blog

Healthcare Kickoff 6 June 2009, Boston, Massachusetts

On 6/6/09, President Obama in his weekly address to the nation to help kickoff his health reform agenda highlighted that: there is an urgent need for health reform this year; the status quo is broken; if we do nothing, everyone’s health care will be put in jeopardy; and that’s why fixing what’s wrong with our health care system is no longer a luxury we hope to achieve – it’s a necessity we cannot postpone any longer. The President’s full address could be accessed: www.WhiteHouse.gov.

Forty empowered Massachusetts residents, including one from Alabama, attended the healthcare reform kickoff on 6/6/09 at Faneuil Hall/Quincy market, Boston and concluded their meeting under the statue of Samuel Adams, who rebelled against the British Empire and gave us our country. We believe the discussions to have, or not to have, healthcare for all is over and it is time for action. We, therefore, respectfully ask our legislators to provide healthcare for all. Our system punishes people when they are sick. The sicker we are the more the punishment. Developed countries reward their citizens when they are sick and the sicker they are the more the reward.

On 10/7/08, candidate Obama, declared, ‘healthcare is a right’. If so, every citizen must be accorded this right. Our legislatures must be accountable to everyone, especially those who need their help the most and those who voted for them. We should now start compiling names of our legislators who oppose universals health coverage, listen to their arguments, respectfully disagree with them and work hard to convince them to be accountable to all. It is our duty, our responsibility and our privilege to do so.

The majority of us who attended the kickoff event were supporters of the public option plan because that is on the table. Advocates of the single payer option plan also attended the meeting. They were pragmatic and engaged in useful discussions. They argued that if enough people push for a single payer option plan, we would definitely end up with a public option plan. Therefore, the debates about the two options were helpful. Everyone agreed that we need a centralized healthcare plan and that the Massachusetts health reform should be considered only as a case study for the Federal health reform agenda. For example, while 97% of Massachusetts’ residents have health insurance, many families who are above 600% of the Federal Poverty Level are not receiving the subsidized health insurance. Families with annual income between 60 – 75 thousands are struggling to keep up with their private health insurance payments (see numbers 4, 9, 12, and 16 below).

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Astroturf

Written by: Harold P on Jun 1, 2009 10:37 AM EDT

Linked to groups: Healthcare Advisors' Blog

Jerry Avorn is a Harvard physician-health researcher who popularized the practice of "academic detailing" in doctors' offices and hospitals to counter the propaganda pitched by pharmaceutical reps. In similar spirit, Avorn recently delivered a well-deserved tongue-lashing to those waging the Astroturf campaign against comparative effectiveness research (CER) http://content.nejm.org/cgi/content/short/360/19/1927.

Avorn's article is surprisingly harsh, considering that it appears in the normally-sedate pages of the New England Journal. He notes the well-orchestrated campaign, brutishly anchored on the right by Rush Limbaugh's attacks on "porkulus," and in more seductive tones by Republican physician-politicians such as Representative Tom Price of Georgia, who warn that CER is the thin end of a wedge leading to government rationing of care.

A recent column by conservative provocateur Betsy McCaughey exemplifies the sheer phoniness of this Astroturf campaign. (If her name seems familiar, McCaughey is most famous for her dishonest, though politically damaging attacks on Hillary-care fifteen years ago.)

In a column called "Ruin your health with the Obama stimulus plan," McCaughey slams Thomas Dashle for promoting the use of CER. Her column is worth quoting at length, in part because it has been widely quoted by Limbaugh and others:

Dashle proposed an appointed body with vast powers to make the "tough" decisions elected politicians won't make.

The stimulus bill does that, and calls it the Federal Coordinating Council for Comparative Effectiveness research (190-192). The goal, Dashle's book explained, is to slow the development and use of new medications and technologies because they are driving up costs. He praises Europeans for being more willing to accept "hopeless diagnoses" and [to] "forego experimental treatments, and he chastises Americans for expecting too much from the health-care system.

Elderly hardest hit

Dashle says health-care reform "will not be pain free." Seniors should be more accepting of the conditions that come with age instead of treating them. This means the elderly will bear the brunt.

Medicare now pays for treatments deemed safe and effective. The stimulus bill will change that and apply a cost-effectiveness standard set by the federal council (464).

Like Dick Morris--who repeatedly fibbed that the Obama health plan would ration healthcare to seniors to finance care for undocumented immigrants http://www.samefacts.com — McCaughey seeks to frighten people with images of Ernest Bevin pushing grandma out on the ice flow in some nightmare image of the British National Health Service, circa 1952.

McCaughey provides a grossly misleading account of cost-effectiveness analysis and how it is actually used in other wealthy democracies. She is even less accurate in describing President Obama's policies and the recent stimulus bill. For example, she leaves out the passage of the new law that reads: "Nothing in this section shall be construed to permit [the Federal Coordinating Council] to mandate coverage, reimbursement or other policies for any public or private payer."

The idea that Democrats are itching to ration care to seniors is hard to reconcile with, well, everything we know about American politics since the New Deal. A standard Republican trope is that Democrats pander to seniors and oppose serious "entitlement reform." Witnessing the increasing costs associated with dementia and other ailments requiring long-term care, it was a Republican, HHS Secretary Michael Leavitt, who warned http://www.huffingtonpost.com/harold-pollack/governor-palin-delivers-l_b_138262.html that "Medicaid must not become an inheritance protection plan." Maybe the graying of the conservative base is leading Republicans to sing in a new key.

Current Republican proposals include much more stringent efforts to constrain and means-test Medicare expenditures. Incidentally, the Kaiser Family Foundation reports that the leading Republican proposal would also "Create a new Health Care Services Commission to establish uniform measures for reporting price and quality information." The HSC, managed by five commissioners from the private sector appointed by the President, will issue a report containing guidelines regulating the publication and dissemination of health care information and will be authorized to enforce these standards." http://www.kff.org/healthreform/upload/healthreform_sbs_full.pdf

When one cuts through the fear-mongering, there is nothing radical or especially liberal, about CER. During the campaign, the Obama and McCain camps squabbled about nearly everything: how to regulate insurers, how much to subsidize poor people, what to do about preexisting conditions, whether to cut Medicare and Medicaid, what to do about stem cells, and more. Come to think of it, though, nobody squabbled about comparative effectiveness research.

There was a good reason for this. Everyone with even basic familiarity with healthcare realizes the insanity of spending $2.4 trillion without having a much better sense of what we are actually getting for our money. Insurers, employers, and parents want to know whether that two-month inpatient adolescent psychiatry stay or that extra costly MRI will really help. We want to know whether that $20,000 lumbar procedure for vague back pain is likely to work. Doctors want to know whether their patients really need the next-generation arthritis medicine when there is a familiar generic backed up by 20 years of safety and efficacy data.

This simple point is well-known across the political spectrum. As John McCain might say with a little impolite straight talk, it's a mighty strange coincidence that the fiercest opponents of CER are medical device and drug companies and surgical subspecialists whose oxen, one suspects, deserve to be gored.

Here, for example, is the view of one scholar http://finance.senate.gov/Gail%20Wilensky.pdf:

The development of more and better information on comparative clinical effectiveness, particularly if its use were encouraged by such concepts as value-based insurance and value based reimbursement, could both improve care quality and potentially slow health care spending….

… These efforts have now been jump-started with the $1.1 billion for comparative effectiveness research provided in the Stimulus bill. As important as this provision is, it needs to be recognized as the first step in what will need to be a long-term commitment in investing in such efforts.

Noting the need to use CER to change the way care is delivered, she went on to add:

[N]ew information alone may not be enough to change physician or patient behavior. Changing incentives for clinicians and their patients, better aligning financial incentives between clinicians and institutional providers and combining information on effectiveness with cost data in setting reimbursement rates will also be important if spending is to change.

These words weren't penned by Tom Dashle or Rahm Emanuel. They were presented last week by Gail Wilensky, a top Republican health expert and a key spokesperson for the McCain presidential campaign.

I often disagree with Wilensky and with other Republican experts such as Douglas Holz-Eakin. Yet these men and women argue within a reality-based community, in which evidence actually matters, and in which political and policy debates are conducted with greater depth and integrity than Betsy McCaughey or Dick Morris can muster. I can hardly imagine more appalling partisan hackery than these two have displayed.

Postscript: Hold the presses. There is something more appalling!

Thanks to great reporting by the Washington Post http://www.washingtonpost.com/wp-srv/politics/health-care/BCBSNC_HealthplanVideo.pdf, we have draft copies of three fearmongering TV commercials commissioned by BlueCross BlueShield of North Carolina that attack proposals to offer consumers a public health care plan. These attack ads on "government-run health care" are peppered with ominous background phrases and questions: "rising premiums," "individual mandate," "preexisting conditions," "what about lines," and more.

Paul Krugman had fun with this in a nice recent column, aptly titled "Blue Double Cross." http://www.nytimes.com/2009/05/22/opinion/22krugman.html?_r=1. He notes that virtually every particular in these ads is misleading. Ironically, background investigation by the watchdog group, Media Matters http://mediamattersaction.org/factcheck/200905190001 indicates that BCBS of North Carolina has a long rap sheet itself—one that includes precisely the missteps and infractions it wrongly insinuates would arise from a public insurance plan.

Now that is chutzpah.

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Howard Dean’s New Book Promotes Health-Care Agenda and Attacks Opponents of Health-Care Reform

Written by: Joe F on Jun 1, 2009 10:05 AM EDT

In Howard Dean’s highly anticipated new book,“Howard Dean’s Prescription for Real Healthcare Reform: How We Can Achieve Affordable Medical Care for Every American and Make Our Jobs Safer," Dean outlines the debate for much needed health-care reform, breaks down the arguments being used by the opposition and makes the case for ensuring a public option for all Americans.

The book will be released as an e-book in all formats the week of June 8, 2009, then will be released as a printed paperback on July 1, 2009.   It will also be released as an iPhone application available for download in the iTunes Store.

In addition to being able to navigate and search the entire book, this interactive book application will allow readers to quickly and easily take action and get involved in the fight for health care reform.

In an official press release from May 29…

Dean argues that for real reform to happen, Americans must have the choice to either keep their existing coverage if they are happy with it, or have the option to select a public plan; and that America must continue to make key investments as President Obama has begun to make in health care information technology to reduce costs and improve the quality of care.

Dean also looks at the devastating impact has had on the American economy adding to job losses as rising health care costs cause a bankruptcy in America every 30 seconds, 14,000 people lose their health insurance every day.  Rising health care costs are also one of the major reasons why small businesses close down and corporations ship jobs overseas.

This new paperback original (and e-book) outlines a practical, pragmatic approach as proposed by President Obama during the 2008 Presidential campaign, and the arguments the opposition will use to prevent a system that includes the 48 million Americans who are forced to live without health insurance:

*Give every American the choice of public or private healthcare insurance

*Public health coverage for life, no matter where you live or work

*No forced moves if the consumer is happy with current coverage

*Small business assistance from the government for employee plans

*No American is disqualified for an existing health condition

*Similar premium costs for everyone, despite age or illness

*Fewer dollars spent on management and more on medicine

“This is the moment when real reform is finally possible. Governor Dean has been a passionate advocate for reform for a long time and, as a physician, has a unique perspective of what is needed and what will actually work”   said publisher Margo Baldwin, representing Chelsea Green Publications. “Anyone who wants to better understand the debate and how to fight back should read this book.  Chelsea Green is honored to publish this important book that will no doubt influence the national debate about healthcare reform.”

Get your copy at...

http://www.chelseagreen.com/bookstore/item/howard_deans_prescription_for_real_healthcare_reform:paperback

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"The tide is turning" on marriage equality in the US, says Howard Dean

Written by: Joe F on May 29, 2009 12:30 PM EDT

Thursday night Howard Dean attended a fundraiser honoring Senate Majority Leader Mike Gronstal and House Speaker Pat Murphy, who both fought valiantly for marriage equality in Iowa .  Dean attended the fundraiser almost immediately following his health-care reform town hall meeting earlier that day in Des Moines.

Opponents of gay marriage in Iowa had been pressing legislators to set the wheels in motion to allow a statewide vote on a constitutional amendment which would ban gay marriage in the state, but both Gronstal and Murphy, the two top Democrats in the State house, would not allow it. 

“I've always thought Gronstal and Murphy were terrific people and I know what it takes to stand up for a decision like this and it takes a lot of courage,” said Dean.  “You always want people in public life who have courage."

Dean saw marriage equality in the US as growing closer than ever before, given the changing attitudes and increased participation in politics by the younger generations of Americans.  As the voting population begins to grow with this younger, more accpeting, and more politically active young Americans, the possbilities for much needed change in American politics is quickly approaching.

               "This new generation is not nearly as divisive or confrontational as my generation,” said Dean in an interview with Radio Iowa. “The tide is turning...For this new generation of Americans, this is just one more minority that's stood up for itself and is now being incorporated into the body politic of America with equal rights."

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The Medicare Prescription Drug Benefit: The Best Example of Why We Need a Public Option in a Reformed Health Care System

Written by: Vicki G on May 26, 2009 10:29 AM EDT

Linked to groups: Healthcare Advisors' Blog

The Medicare Prescription Drug Benefit: The Best Example of Why We Need a Public Option in a Reformed Health Care System By Vicky Gottlich Opponents of a public plan option in any health care reform exchange system cite to the Medicare prescription drug benefit, known as Medicare Part D, as an example of a successful insurance program offered exclusively through private insurance companies. Unlike the hospital and doctor portions of Medicare, where services are available through the traditional public program or through private managed care plans, Medicare drug benefits are available only through private insurance companies. Older people and people with disabilities who want Medicare drug coverage must choose and then enroll in one of the private options, either a stand -alone insurance plan that covers only prescriptions or a managed care plan that includes drug coverage. Public plan opponents claim that Part D works well and is a model to be followed.

My experience as an advocate who helps Medicare beneficiaries navigate the Part D program has convinced me - and others who do similar work - that the opposite is true. Rather than being the example of how the private market works well without a public insurance option, the Medicare Part D program is the best argument for including a public health plan option in health care reform. A public option is needed to help control costs, to keep coverage affordable, and to ensure that the needs of high-cost consumers are met. None of that happens in Medicare Part D.

Without a public drug benefit option, the Medicare Part D costs to Medicare beneficiaries have risen substantially since the program went into effect in 2006. Premiums for plans offered by two of the sponsoring organizations with the largest enrollment, Humana and UnitedHealth Group, have risen 210% and 143%, respectively, since 2006. About half of beneficiaries who remain in the same stand-alone prescription drug plan since 2006 will have experienced a 50% increase in their premiums since the program began. Thus, the prescription drug benefit is becoming less affordable for many beneficiaries.

The premium increase is in addition to other increases in cost-sharing amounts and in the cost of drugs. AARP reports that the cost of brand name and the highest cost drugs placed in specialty cost-sharing tiers (a Part D phenomenon) continues to increase at a rate faster than inflation. Although the overall price of generic drugs has declined, the increased cost for brand and specialty drugs offsets the savings in cost for generic drugs. When drugs cost more, beneficiaries who are charged a coinsurance amount pay more out-of-pocket. And all beneficiaries pay more when they reach the “donut hole” or coverage gap, where, by Congressional design, they pay the full cost of their drugs and the insurance premium until they have spent enough on drugs for the year for catastrophic coverage to kick in.

In addition, the Part D benefit packages are not friendly to people who need drug coverage the most. Like the few private insurance plans that were available to older people before Medicare was enacted in 1965, the private Part D plans are designed to discourage enrollment by high health care users. In 2009, no stand-alone drug plan offers coverage of brand name drugs in the coverage gap or donut hole, (there are no generics for some drugs older people need) and plans continue to reduce the gap coverage that they do offer. The number of plans that have specialty tiers for high cost drugs has increased, as has the cost sharing charged for drugs on the specialty tiers. Although beneficiaries who require specialty tier drugs will reach catastrophic coverage sooner, many cannot afford the 35% cost –sharing on drugs that, by definition, cost $600 or more per fill. Even for drugs that are on lower cost-sharing tiers, plans have increased the utilization management requirements in their formularies, making it harder for people to get the drugs that were prescribed for them.

The most vulnerable of all enrollees, those eligible for the low-income subsidy (LIS) that defrays premiums, most cost sharing, and provides coverage in the donut hole, have experienced the greatest upheaval as a result of reliance only on private plans. Because of business decisions made by the plan sponsors, the plans that qualify as zero premium or benchmark plans change each year. Less than one-quarter of the plans that qualified as benchmark plans in 2006 so qualify today, and the total number of benchmark plans available have declined substantially. This yearly churning in benchmark plans necessitates millions of beneficiaries (2.2 million sin 2008) to either change to a different plan for which they will pay no premium or to remain in their previous plan and pay a portion of the premium. Most of these people are reassigned to a new play by CMS, but reassignments cause disruption in care, as beneficiaries must contend with new formularies, new utilization management requirements, and new plan procedures. Those who remain in their previous plan often cannot afford even the minimal premium amounts, and some are being disenrolled for non-payment.

Congress anticipated that beneficiaries would change drug plans each year in response to increases in drug plan premiums and cost sharing. Data show, however, that most beneficiaries have not changed plans, citing the complexity of the Part D program. After all, there are over 50 different stand-alone drug plan choices in most communities, and often as many managed care options, each with its own premium, drug formulary, cost-sharing schemes, and hoops that must be gone through to get some drugs that were prescribed by a treating physician.

To recap: Premiums for the Medicare Part D prescription benefit have increased exponentially and at a greater rate than premiums in the private employer-sponsored market. Cost sharing on covered drugs has gone up at the same time the plans have increased restrictions on access to some drugs and reduced the extra coverage they offer for people whose high drug costs put them in the “donut hole.” These changes have the greatest impact on individuals who need prescription drugs the most. The Part D plans have not been successful in keeping the overall cost of drugs down. Nor have they done a good job in protecting and providing continuous care to the lowest income older people and people with disabilities. That’s what we get in a system that relies on the private market to provide health care. Isn’t that proof enough that we need a public plan option if we really want to provide affordable, quality health care while reducing health care costs?


1. The Leadership Council on Aging Organizations recommends that a public drug plan option be offered through the traditional Medicare program.
http://www.lcao.org/docs/health/LCAO-HCReformDoc-FINAL.pdf
2. Source: Presentation by Avalere Health of their analysis using DataFrame®, a proprietary database of Medicare Part D plan features and 2009 MA-PD plan data released September 25, 2008 by CMS.
3. Kaiser Family Foundation, Medicare Part D Data Spotlight: Premiums (November 2008), http://www.kff.org/medicare/upload/7835.pdf
4. AARP, Rx Watchdog Report: Trends in Manufacturer Prices of Prescription Drugs used by Medicare Beneficiaries – 2008 Year End Update (April 2009), http://www.aarp.org/research/medicare/drugs/rx_watchdog.html
5. Kaiser Family Foundation, Medicare Part D Data Spotlight: The Coverage Gap (November 2008), http://www.kff.org/medicare/upload/7834.pdf
6. Kaiser Family Foundation, Medicare Prescription Drug Plans in 2008 and Key Changes Since 2006: Summary of Findings (April 2008), http://www.kff.org/medicare/upload/7762.pdf
7. Medicare Part D Data Spotlight: Low-Income Subsidy Plan Availability (November 2008), http://www.kff.org/medicare/upload/7836.pdf.
8. Kaiser Family Foundation, Choosing a Medicare Part D Plan: Are Beneficiaries Choosing Low-Cost Plans? (March 2009) http://www.kff.org/medicare/7864.cfm

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