This paper, by Joy Pritts of the Health Policy Institute at Georgetown University, looks at issues related to drug plan marketing activities and privacy under the MMA.

Issue Brief (.pdf)

Prescription Drug Costs

Download a printable .pdf of Health Care and the 2004 Elections: Prescription Drug Costs.

IssueBackgroundOptions for for making prescription drugs more affordableAssessing Candidate PositionsIssue

Health care costs in general have grown faster than the economy. Although still only a modest part of total health care spending in the United States (11% in 2002), the growth in pharmaceutical spending has outpaced other categories of health care services over the last few years. What, if anything, should the government do to make prescription drugs more affordable?

Background

Developments in pharmaceuticals have transformed health care over the last several decades. Today, many diseases are prevented, cured, or managed effectively for years through the use of prescription drugs. In some cases the use of prescription drugs keeps people from needing other expensive health care such as being hospitalized or having surgery.

These advances have not come without a price. In 2002, spending on prescription drugs in the U.S. grew 15 percent compared to a 9 percent increase for all health care. ¹ This growth in spending on prescription drugs is due to three factors: increased use of prescription drugs in general, the higher costs for new products coming to market and replacing existing drugs, and increases in drug prices. In 2002, the average price of a retail prescription grew almost 6 percent, reflecting the influence of newer, higher priced prescription products in the market. ²

The prices for prescription drugs reflect the consumer demand, or willingness to pay for medications, and the patent system, which encourages manufacturers to invest in developing new drugs. Consumer demand has been affected by the growth in private third-party payment for pharmaceutical products, which means that consumers directly see only a small part of increasing drug costs when they fill a prescription. ³ Another possible factor has been the growth in direct-to-consumer marketing of pharmaceutical products, which encourages consumers to ask their doctors about new medications ⁴,while increasing their knowledge about drug options.

Patents affect prices by providing manufacturers who develop new pharmaceutical products an exclusive right to sell the drug for 20 years from the date of the patent filing. ⁵ The actual costs for making most prescription drug products are relatively small (although such costs may be significantly higher in some cases, such as for biotechnology products), and thus, the prices for a drug are usually considerably lower once the patent expires and generic competition enters the market. Therefore, the company that developed the drug must recoup its investment and make most of its profit on a product during the period it has the patent. Once the patent expires, the drug may be manufactured in generic versions by any number of manufacturers. ⁶ Even during the patent years, other products to treat the same condition may come to market, producing price competition among therapeutic options.

Manufacturers make substantial investments in the products that they bring to market, and to be profitable, they must recoup not only the development costs of successful drugs and devices, but also, the costs for research and development for products that never make it to market. Only one in five medicines that enter the clinical testing process ever gain Food and Drug Administration (FDA) approval and enter the market. ⁷ Thus far, however, drug makers have been able to make a profit. From 1995 through 2002, pharmaceutical manufacturing was the most profitable industry in the U.S. Profitability declined somewhat in 2002, and in 2003 it ranked third with profits after taxes of about 14 percent. ⁸

The cost of prescription drugs has commanded considerable public attention over the last decade. People with coverage for their prescription expenses have seen their cost-sharing for brand products increase substantially as employers and health plans move to arrangements which provide financial incentives for consumers to use lower cost drugs. ⁹ People without drug coverage, including many Medicare beneficiaries, often pay the highest prices for prescription medications, and must confront rapid cost increases directly. In response to concerns over the out-of-pocket cost burdens on the elderly and disabled, Congress passed a law last year that provides new Medicare outpatient prescription drug benefits that will be available beginning on January 1, 2006. While government assistance will be comprehensive for low-income beneficiaries, the benefits for others are such that many Medicare beneficiaries will still be paying large amounts out-of-pocket for their medicines.

Options for for making prescription drugs more affordable

While there are a number of policy options under consideration for addressing rising drug costs, the two that are currently receiving the most political attention are reimportation and the government’s role concerning drug prices in the Medicare program.

Importation. Proposals that would allow Americans to purchase drugs from other countries are referred to under the terms “importation” or “reimportation”. ¹⁰ It is currently illegal to import prescription drugs into the U.S. from other countries, and only the original manufacturer may reimport a pharmaceutical product, subject to meeting certain standards on how they are handled and labeled. In practice, however, the FDA, which is the federal agency responsible for overseeing pharmaceutical products, does not enforce the law banning importation in certain circumstances where drugs are imported for personal use.

The significantly lower prices available for common prescription drugs in bordering countries, Canada and Mexico, has led some Americans to import drugs from those countries and has encouraged politicians of both parties to propose lifting the import ban. Congress has passed legislation allowing for expanded importation of drugs on several occasions but the laws were never implemented because they required that the Secretary of the Department of Health and Human Services (HHS) conclude that safety could be maintained and that costs would significantly be reduced. Both HHS Secretary Shalala in the Clinton Administration, and Secretary Thompson in the Bush Administration concluded that they could not meet these standards.

A number of bills on importation have been introduced in the current Congress. The bills differ in a number of ways. Some would allow drugs to be imported only for personal use while others would allow imports for commercial purposes. The bills also differ in terms of the countries from which drugs could be imported, safety standards, regulatory requirements, and fees that would be levied to help pay the costs of increased government regulation. In addition, a number of states, including Illinois, Iowa, Michigan, Minnesota, and Ohio, as well as a number of cities, have undertaken efforts to get lower drug prices for their residents through purchase from other countries. They are doing this in order to reduce state costs for providing drug benefits to state employees, or to make it easier for their residents to import drugs. Although the FDA has not approved these efforts, it also as yet has not stopped them.

Would allowing importation result in lower prescription drug costs for American consumers? There are varying opinions on this issue, but most experts caution that savings cannot be guaranteed, especially if importation is limited to only certain countries, such as Canada. ¹¹ The Congressional Budget Office (CBO), the agency responsible for estimating the financial impact of federal policy changes, concludes that the effect would be small. ¹² It acknowledges that prices for drugs still under patent protections (as opposed to generic products) are 35 percent to 55 percent lower in other countries than in the U.S. However, it cautions that responses by foreign governments and by the pharmaceutical industry to such a change in policy could erode most savings. For example, foreign governments could restrict the supply of drugs leaving their borders; or pharmaceutical manufacturers could limit the supply of drugs sold to foreign nations that facilitate sales to U.S. purchasers.

On the other hand, those who advocate in favor of allowing importation acknowledge that drug importation limited only to Canada would not be a long-term solution. ¹³ They believe that if importation were legal from other countries, including the Asian and European markets, as well as from Canada, there would be enough volume to significantly affect prices in the U.S. market. ¹⁴ They also believe that the potential of lower prices from foreign countries will cause U.S. pharmacies to cut their prices in order to be competitive. At the very least, they feel that the debate around importation makes people aware of the fact that prices are lower in other countries and puts continued pressure on drug makers to keep their U.S. prices in check.

Supporters of importation also argue that the safety issue can be addressed. For example, legislation which passed the U.S. House of Representatives with bipartisan support would limit reimportation to FDA-approved drugs manufactured in FDA-approved facilities in 25 countries, require the use of counterfeit-resistant packaging (or testing of each pharmaceutical shipment that does not use such packaging), and give the Secretary of Health and Human Services the power to immediately halt importation if a product violates the law. ¹⁵ Opponents argue that these safeguards are not adequate. Bills on importation that have been introduced in the Senate are still awaiting action and may not be debated before Congress adjourns.

Government’s role in Medicare drug prices. The second visible issue in the 2004 campaign relating to drug prices involves the appropriate role for government regarding drug prices for Medicare beneficiaries. The Medicare Modernization Act of 2003, which establishes outpatient prescription drug coverage for Medicare beneficiaries beginning in 2006, relies on competition among private health plans to make drugs available to beneficiaries at reasonable prices. Medicare beneficiaries who wish to participate in the new program will have to enroll in one of the Medicare drug plans available to them in their area of residence. Each plan will be responsible for negotiating with drug manufacturers and pharmacies to determine the prices for medicines that will apply under the plan. Because the drug benefits are limited for beneficiaries who are not low-income, many seniors will have access to lower prices, but will also still have significant out-of-pocket costs for their medicines. The law specifically prohibits the government from interfering in the negotiations between the drug plan sponsors and drug manufacturers and pharmacies. It also prohibits the government from establishing any specific list of drugs that will be covered (formulary) or imposing any price controls on drugs.

Supporters of the market-based approach in the new Medicare law believe that the competition for enrollees will cause plans to negotiate with drug manufacturers and pharmacies to offer drugs at the lowest possible prices. They believe that permitting the government to set prices for Medicare would not necessarily guarantee lower prices, may have unintended consequences on the rest of the market, and would negatively affect patients because government price controls would stifle industry incentives to invest in research and development of new therapies.

Some people argue that the current market-based tools being used by health plans and pharmaceutical benefit managers (PBMs) have not been effective, and that prices for brand pharmaceutical products are considerably higher in the U.S. than in other countries where governments take a more active role in negotiating prices and rates of return with manufacturers. It should be noted that the federal government regulates prescription drug prices in the fee-for-service Medicaid program and the veterans’ health program. ¹⁶ Opponents of market-based tools also suggest that in cases where manufacturers have exclusive rights for drugs with few or no competitors, competition may have little or no impact on price. They support removing from the law the ban on government interference and price setting, and granting the government the authority to directly negotiate prices with manufacturers. Some advocate that this authority not be used unless the private plans are not able to achieve lower prices. Other options include using this power only for certain drugs for which there is no competition.

Assessing Candidate Positions

While there is no clear partisan division between Republicans and Democrats on the issue of importation, candidates tend to be more divided regarding government intervention in drug pricing, aligning themselves with those who support a market-based approach versus those who favor more government intervention. Included below are a series of questions to help evaluate candidate positions on prescription drug costs.

• Should the U.S. allow people to buy prescription drugs from other countries? Under what circumstances?
• What can be done to assure the quality and safety of prescription medicines imported into the U.S.?
• If people in the U.S. are allowed to import drugs, will drug companies invest less in research and development? If so, are there any measures the government can take to encourage companies to do research and development?
• Is a market-based system or government intervention the most effective way to control drug costs for seniors? If prescription medicines remain unaffordable for many seniors after the Medicare drug law goes into effect, what approach should be taken?

Prepared by Health Policy Alternatives, Inc.

¹ National Health Expenditures Tables. http://www.cms.hhs.gov/statistics/nhe/historical/t2.asp.² Lundy, Janet, Benjamin Finder, and Gary Claxton. Trends and Indicators in the Changing Health Care Marketplace, 2004 Update. Kaiser Family Foundation. April 2004. Exhibit 1.18.³ The percentage of prescription drug costs paid for by private health insurance increased from 24 percent in 1990 to 47 percent in 2001. Fact Sheet: Prescription Drug Trends, Kaiser Family Foundation, May 2003. Figure 2.⁴ Rosenthal, Meredith B., et al. Demand Effects of Recent Changes in Prescription Drug Promotion, Kaiser Family Foundation, June 2003. Direct to consumer advertising rose by 28 percent annually between 1996 and 2001. The study found that increases in direct-to-consumer advertising between 1999 and 2000 accounted for 12 percent of drug sales growth during that period.⁵ However, the effective patent period is usually shorter because patents are obtained before the products are approved for marketing.⁶ Often, in order to extend their favorable market situation, a company may get a new patent on a slightly different version of a drug about to go off patent.⁷ Di Masi, Joseph A. “Success Rates for New Drugs Entering Clinical Testing in the United States,” 58 Clinical Pharmacology and Therapeutics, 1995, p. 1-14.⁸ Lundy, Janet, Benjamin Finder, and Gary Claxton. Trends and Indicators in the Changing Health Care Marketplace, 2004 Update. Kaiser Family Foundation. April 2004. Exhibit 1.21.⁹ Between 2000 and 2004, copayments in multi-tier arrangements increased by 62 percent for preferred brand drugs and by 94 percent for non-preferred brand drugs. Henry J. Kaiser Family Foundation and Health Research and Educational Trust, Employer Health Benefits Annual Survey, 2000 and 2004.¹⁰ Importation refers to bringing products into the U.S. from other countries, whereas reimportation means bringing back into the U.S. products that were produced here and exported to another country.¹¹ Schuler, Kate. Weighing Promise and Perils of Drug Importation. CQ Weekly, July 24, 2004. p. 1791.¹² CBO. Would Prescription Drug Importation Reduce U.S. Drug Spending, April 29, 2004. http://www.cbo.gov/showdoc.cfm?index=5406&sequence=0¹³ Families USA. Written testimony submitted to the U.S. Committee on Finance, Hearing on International Trade and Pharmaceuticals, April 27, 2004.¹⁴ Schuler, Kate. Weighing Promise and Perils of Drug Importation. CQ Weekly, July 24, 2004. p. 1790.¹⁵ See H.R. 2427 (108th Congress).¹⁶ For example, in Medicaid, the government requires manufacturers to provide rebates to state governments for outpatient drugs, effectively reducing the price the state pays for the drug.

Papers on Issues For People With Medicare Raised By Proposed Drug Benefit Regulations

The Kaiser Family Foundation has commissioned a series of papers to explore key issues that may be of concern for Medicare beneficiaries as the new Medicare drug benefit is implemented. These papers focus on specific areas of potential concern for people with Medicare. In addition, the Foundation also has produced a timeline of upcoming important dates leading up to the implementation of the new drug benefit.

Issue Paper — Marketing and Privacy Issues: An Analysis of the MMA and Proposed Regulations

Issue Paper — Issues for Medicare Beneficiaries in Long-Term Care Facilities: An Analysis of the MMA and Proposed Regulations

Issue Paper — Grievance and Appeals Procedures: An Analysis of the MMA and Proposed Regulations

Issue Paper — The Effect of Formularies and Other Cost Management Tools on Access to Medications: An Analysis of the MMA and Proposed Regulations

Timeline — Medicare Prescription Drug Improvement and Modernization Act Implementation Timeline: June 2004 – December 2006 Key Dates

This comprehensive survey of people on Medicare, conducted in June and July 2004, assesses their attitudes toward the new Medicare drug law. This chartpack, issued in September 2004, presents additional analysis on the survey data, looking at key findings broken down by income group.

Chartpack (.pdf)

This paper, by Sara Rosenbaum, J.D., Director of the Center for Health Services Research and Policy at George Washington University, examines the procedures for resolving beneficiaries’ grievances and appeals under the new Medicare drug benefit. It is one in a series commissioned by the Kaiser Family Foundation that analyzes issues surrounding the implementation of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and the proposed regulations.

Issue Brief (.pdf)

Health Care Costs

Download a printable .pdf of Heath Care and the 2004 Elections: Health Care Costs.

IssueBackgroundSources of Cost IncreasesCost Control StrategiesImpact of the ElectionAssessing Candidate Positions

Issue

Health cost increases threaten to make health insurance less affordable for all Americans, and make it harder to extend coverage to the 45 million Americans who are uninsured. Rising health costs are also taking a larger share of government spending at a time of high and continuing budget deficits. Strategies for moderating growing health costs may include a strong role for government negotiation or market-based models relying on competitive forces. How the candidates for the upcoming election propose to address these challenges is a critical component of the current political debates.

Background

Since the 1960s, the nation’s efforts to control health care costs through either government regulation or market forces have not had much long-term effect. ¹ After a brief respite in the mid-1990’s, expenditures on health care are again growing at rapid rates, significantly outpacing inflation and the growth in national income. Total health care expenditures grew at an annual rate of 9.3 percent between 2001 and 2002, pushing health spending from 14.1 to nearly 15 percent of the U.S. economy over the period. Health spending in the U.S. totaled $1.6 trillion in 2002 (the last year for which there is complete information), or about $5,400 per person, by far the highest per capita spending on health care in the world. ²

Although Americans benefit from this increasing investment in health care, recent rapid cost growth, coupled with an overall economic slowdown, is placing great strains on the systems we use to finance health care, including private employer-sponsored health insurance coverage and public insurance programs such as Medicare and Medicaid. Since 2000, employer-sponsored health coverage premiums have increased by nearly 60 percent for family coverage, with family premiums increasing 11.2 percent between 2003 and 2004. ³ Medicare and Medicaid program spending have also been increasing, but at lower rates than employer plan premiums.

In the shorter term, policymakers and other private payers for care are seeking ways to reduce cost growth and improve efficiency. Absent aggressive efforts at cost control, however, advances in medicine and the growing elderly population will almost inevitably cause health care spending to grow faster than the economy overall. In the longer term, the nation faces the question of how to finance the health care’s growing share of national resources.

The challenges facing policymakers are made more difficult by unprecedented federal deficits, which are projected to continue over at least the next 10 years – totaling some $2.3 trillion. ⁴ These fiscal pressures are likely to intensify efforts to slow growth in health spending for programs like Medicare and Medicaid. Further, nearly 45 million Americans, many with low incomes, are without any health coverage, and providing them with access to coverage – either by expanding government programs or providing subsidies through tax credits –– will increase rather than decrease total spending. ⁵

And, despite the fact that the U.S. devotes significantly more of its national income to health than other countries high level of health spending in the U.S, performance on a number of important health status indicators lags that of a number of other industrialized countries. Specifically, 2001 data from the Organization for Economic Cooperation and Development (OECD) on 26 nations shows 23 countries with lower infant mortality rates, and 17 nations with longer life expectancy than in the U.S. ⁶ While the level of investment in health care is only one factor affecting health status, U.S. rankings suggest that the benefits of spending on health are not evenly distributed.

Sources of Cost Increases

Costs for each of the major components of health care spending have risen faster than inflation in recent years. Between 2001 and 2002, the last year for which we have complete information, nearly one-third of the growth in health spending was due to increases in spending on hospital care. Increased consolidation and mergers have given hospitals more negotiating clout, allowing them to charge higher prices for their services. Of the 9.5 percent increase in hospital spending in 2002, higher prices accounted for 5 percent of the growth. ⁷ Much of the rest of the increased spending is attributable to more hospital admissions and increases in the amount of services given to hospital patients.

Prescription drugs costs are widely assumed to be responsible for much of the increase in overall health spending. While drug spending increased 15.3 percent in 2002, it represents only 11 percent of total health spending and about 16 percent of the increase in all health care spending for the year. ⁸ In fact, spending for drugs has been declining over the past three years probably as a result of higher co-pays, more use of generic drugs, and tighter controls on drug coverage by private insurers and Medicaid.

Physician spending growth declined in 2002 to 7.7 percent compared to the 8.6 percent increase recorded in 2001. ⁹ Limitations on Medicare physician payments are assumed to account for the slower growth in overall spending. One factor that is often cited for contributing an increase in health care costs is the practice of defensive medicine by doctors due to a fear of malpractice claims. While physicians often cite the high cost of professional liability insurance, according to the Congressional Budget Office (CBO), spending on malpractice insurance accounts for less than 2 percent of total health spending. Although malpractice premiums continue to escalate at about 15 percent a year, CBO states that significant reductions in this rate of growth would only modestly affect overall health spending growth. ¹⁰

The remaining one-third of health spending increases is attributable to spending for nursing homes, home health care, and other items of medical equipment and supplies. Spending for home health care rose by 7.2 percent in 2002, primarily as a result of higher Medicare payments and an expansion in Medicare coverage of home care. ¹¹

While more recent data record a slow down in the rate of increase in health spending, most observers predict that future increases will continue to outstrip growth in the overall economy and wages. These trends will make health insurance less affordable, increase out-of-pocket spending, and require larger public outlays at a time of rising budget deficits.

Cost Control Strategies

Cost containment strategies are likely to be pursued by government and private purchasers of health care – insurance plans and employers. Government policies intended to reduce the increase in spending for Medicare and Medicaid will be on the public policy agenda regardless of the election outcome. Meanwhile, employers and insurance plans will continue to search for ways to slow spending increases by using their leverage in the market to hold the line on price increases, by shifting costs to workers in the form of higher premiums, deductibles, and co-payments, and by attempting to use innovations such as disease management to head off more expensive health care interventions with tailored guidance and care for commonplace, chronic diseases.

At the political level, much of the discussion about health care costs has centered on the greater burden of costs to employers and individuals. Some think introducing more consumer involvement into health care spending decisions is an answer. Supporters of new “consumer-driven” health plans – consisting of tax-favored savings accounts and catastrophic insurance for expenses beyond a high annual deductible – believe that providing consumers with more information about their health care choices, coupled with strong financial incentives to be prudent purchasers of services, will result in lower cost growth. Advocates of this approach favor greater price transparency so that consumers can make more informed choices and more reliance on personal savings accounts for health care that allow patients to control routine health spending. Critics of this approach raise concerns about the potential impacts that the higher cost-sharing would have on lower income people, about the potential for these new arrangements to be disproportionately used by healthy people, and about the risk that important health care services will be forgone.

Others have called for a more direct role for government in containing health costs. They cite the success of Medicare policies in reducing the increase in per capita spending over the history of the program. The adoption of prospective payment systems in Medicare that shift financial risk for benefit costs to providers, and increased reliance on fee schedules and competitive bidding as the basis for other provider payments have been, in their view, effective in moderating Medicare spending growth. These payment policies have been widely adopted by private insurers as well. Direct government negotiation of prescription drug prices by the veterans health system is also cited as an example of government cost controls that have significantly lowered costs. Critics of this government role argue that such regulation imposes its own costs by stifling innovation, and preserving inefficient ways of delivering health care.

In sum, advocates of a stronger direct government role in health cost containment cite the Medicare and veterans health system experience, and point out that market-based approaches combined with greater individual financial responsibility can disadvantage those with limited financial resources and create barriers to needed care. Proponents of market-based approaches argue that consumers will benefit from a wider range of choices for their health coverage and that competition for enrollees will result in more effective cost containment benefiting consumers and all other purchasers of health care services.

Other political debates about health care costs have been focused on specific issues or parts of the market. Rapidly increasing costs for prescription drugs have generated several different cost containment proposals. One approach that receives substantial bipartisan support would permit people to purchase drugs that have been imported from Canada or other countries. These proposals would take advantage of price limits negotiated by other countries to lower the costs of drugs in the U.S. Opponents of this approach argue that it is merely importing government price controls. Moreover, lowering drug prices below market levels would reduce manufacturers’ financial incentives to develop new therapies. Supporters of this approach argue that Americans are subsidizing the citizens of other countries by paying higher prices for drugs, and that permitting drugs to be imported from other countries would result in a more fair allocation of drug costs across countries. The Congressional Budget Office has noted that this approach would have little long-run impact because both manufacturers and the governments in exporting countries would have strong incentives to end the practice. ¹²

Another focus of the health care cost debate has been medical malpractice; in particular the recent rapid increases in medical malpractice premiums and the overall impact of medical malpractice claims on health care costs. Proposals split largely but not entirely across partisan lines, with Republicans generally supporting caps on non-economic (pain and suffering) and punitive damages, and other changes to the legal system for resolving medical malpractice claims. Proposals often made by Democrats include: excluding amounts awarded in binding arbitration from taxable income (e.g., encouraging the use of alternative dispute resolution rather than the courts), elimination of the Federal antitrust exemption for insurers, establishment of a Federal reinsurance program to cover damage awards above a specified threshold, and tougher penalties for frivolous malpractice lawsuits.

There is substantial disagreement over the potential impacts of any of these different approaches, both on compensation for victims and on overall costs. However, a recent Congressional Budget Office report concluded that even large reductions in malpractice premiums would have only a “small direct impact on health spending.” The report also observes that the evidence for lower health costs as a result of reducing the amount of ‘defensive medicine’ is “weak or inconclusive. ¹³

The Impact of the Election

While the two major candidates for president have not released a specific set of proposals to slow the growth in health spending, both candidates talk about making health care more affordable – at least in some targeted way – by cutting the cost of drugs, reducing malpractice premiums, using information technology to make the system more efficient, or helping both employers and individuals reduce their insurance costs. Neither candidate has put forward a comprehensive plan for slowing increases in health costs in the aggregate.

Assessing Candidate Positions

1. How can health care be made more affordable without limiting access to necessary care?
2. What role should government play in controlling increases in the cost of care and the cost of health coverage?
3. What is the responsibility of individuals in the cost of their care? Are health savings accounts and high deductible insurance policies an approach that should be expanded?
4. What is the best approach to protect low-income Americans from unaffordable out-of-pocket costs for health care while containing health costs overall?
5. Should the government negotiate prices for prescription drugs? Should Americans be permitted to import drugs from foreign countries? How could the cost of malpractice insurance be reduced while assuring patients timely and appropriate compensation for medical injuries?

¹ Drew Altman and Larry Levitt, “The Sad History of Health Care Cost Containment As Told in One Chart,” Health Affairs, January 23, 2002.² Katharine Levit, et. al., “Health Spending Rebound Continues in 2002,” Health Affairs, v. 23, no.1, January/February 2004.³ Henry J. Kaiser Family Foundation and Health Research and Educational Trust, Employer Health Benefits: 2004 Annual Survey, September 2004, http://www.kff.org/insurance/ehbs/7148 (date accessed).⁴ “The Budget and Economic Outlook: An Update,” Congressional Budget Office, September 2004. ⁵ Current Population Surveys, Census Bureau, U.S. Department of Commerce, August 2004.⁶ “OECD Health Data 2004-Frequently Requested Data,” Organization for Economic Co-operation and Development, June 3, 2004.⁷ Katharine Levit, et. al., “Health Spending Rebound Continues in 2002,” Health Affairs, v. 23, no.1, January/February 2004. ⁸ Katharine Levit, et. al., Health Affairs, v. 23, no.1, January/February 2004. ⁹ Katharine Levit, et. al., Health Affairs, v. 23, no.1, January/February 2004. ¹⁰ “Limiting Tort Liability for Medical Malpractice,” Congressional Budget Office, January 8, 2004. ¹¹ Katharine Levit, et. al., Health Affairs, v. 23, no.1, January/February 2004. ¹² “Limiting Tort Liability for Medical Malpractice,” Congressional Budget Office, January 8, 2004. ¹³ “Limiting Tort Liability for Medical Malpractice,” Congressional Budget Office, January 8, 2004.

• pdf of Health Care and the 2004 Elections: Public Opinion

This paper, by Vicki Gottlich, J.D., of the Center for Medicare Advocacy, looks at issues related to the new Medicare prescription drug benefit for people with Medicare who live in nursing homes or other long-term-care settings. It is one in a series commissioned by the Kaiser Family Foundation that analyzes issues surrounding the implementation of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and the proposed regulations.

Issue Brief (.pdf)

This issue paper presents information from nine states that have developed and implemented disease management programs for adult Medicaid enrollees with chronic conditions such as asthma, diabetes, and congestive heart failure, or who are trying to manage these populations through capitated managed care. It examines the motivations, goals, strategies and impact of these state efforts, in addition to describing the details of their initiatives.

Issue Paper (.pdf)

Parents, Media and Public Policy: A Kaiser Family Foundation Survey

“Parents, Media and Public Policy,” a new national survey from the Kaiser Family Foundation, explores how parents feel about media content and ratings systems. The survey found that a majority of parents say they are “very” concerned about the amount of sex (60%) and violence (53%) their children are exposed to on TV. The survey of 1,001 parents of children ages 2-17 was conducted in July and August 2004.

Survey Report (.pdf)