spending and has held average annual drug spending by seniors in absolute dollars fairly constant for over 10 years. many look to the veterans health administration as a model of lower cost prescription drug coverage. since the vha provides healthcare directly, it maintains its own formulary and negotiates prices with manufacturers. studies show that the vha pays dramatically less for drugs than the pdp plans medicare part d subsidizes. one analysis found that adopting a formulary similar to the vha's would save medicare $14 billion a year. there are other proposals for savings on prescription drugs that do not require such fundamental changes to medicare part d's payment and coverage policies. manufacturers who supply drugs to medicaid are required to offer a 15 percent rebate on the average manufacturer's price. low-income elderly individuals who qualify for both medicare and medicaid receive drug coverage through medicare part d, and no reimbursement is paid for the drugs the government purchases for them. reinstating that rebate would yield savings of $112 billion, according to a recent cbo estimate. some have questioned the ability of the federal government to achieve greater savings than the largest pdps, since some of the larger plans have coverage pools comparable to medicare's, though the evidence from the vha is promising. some also worry that controlling the prices of prescription drugs would reduce incentives for manufacturers to invest in r&d, though the same could be said of anything that would reduce costs. however, the comparisons with the vha point out that the va only covers about half the drugs as part d. reforming care for the "dual-eligibles" roughly nine million americans—mostly older adults with low incomes—are eligible for both medicare and medicaid. these men and women tend to have particularly poor health—more than half are being treated for five or more chronic conditions—and high costs. average annual per-capita spending for "dual-eligibles" is $20,000, compared to $10,900 for the medicare population as a whole. the dual-eligible population comprises roughly 20 percent of medicare's enrollees but accounts for 36 percent of its costs. there is substantial evidence that these individuals receive highly inefficient care because responsibility for their care is split between the medicare and medicaid programs—most see a number of different providers without any kind of mechanism to coordinate their care, and they face high rates of potentially preventable hospitalizations. because medicaid and medicare cover different aspects of health care, both have a financial incentive to shunt patients into care the other program pays for. many experts have suggested that establishing mechanisms to coordinate care for the dual-eligibles could yield substantial savings in the medicare program, mostly by reducing hospitalizations. such programs would connect patients with primary care, create an individualized health plan, assist enrollees in receiving social and human services as well as medical care, reconcile medications prescribed by different doctors to ensure they do not undermine one another, and oversee behavior to improve health. the general ethos of these proposals is to "treat the patient, not the condition," and maintain health while avoiding costly treatments. there is some controversy over who exactly should take responsibility for coordinating the care of the dual eligibles. there have been some proposals to transfer dual eligibles into existing medicaid managed care plans, which are controlled by individual states. but many states facing severe budget shortfalls might have some incentive to stint on necessary care or otherwise shift costs to enrollees and their families to capture some medicaid savings. medicare has more experience managing the care of older adults, and is already expanding coordinated care programs under the aca, though there are some questions about private medicare plans' capacity to manage care and achieve meaningful cost savings. estimated savings from more effective coordinated care for the dual eligibles range from $125 billion to over $200 billion, mostly by eliminating unnecessary, expensive hospital admissions. income-relating medicare premiums both house republicans and president obama proposed increasing the additional premiums paid by the wealthiest people with medicare, compounding several reforms in the aca that would increase the number of wealthier individuals paying higher, income-related part b and part d premiums. such proposals are projected to save $20 billion over the course of a decade, and would ultimately result in more than a quarter of medicare enrollees paying between 35 and 90 percent of their part b costs by 2035, rather than the typical 25 percent. if the brackets mandated for 2035 were implemented today, it would mean that anyone earning more than $47,000 (as an individual) or $94,000 (as a couple) would be affected. under the republican proposals, affected individuals would pay 40 percent of the total part b and part d premiums, which would be equivalent of $2,500 today. more limited income-relation of premiums only raises limited revenue. currently, only 5 percent of medicare enrollees pay an income-related premium, and most only pay 35 percent of their total premium, compared to the 25 percent most people pay. only a negligible number of enrollees fall into the higher income brackets required to bear a more substantial share of their costs—roughly half a percent of individuals and less than three percent of married couples currently pay more than 35 percent of their total part b costs. there is some concern that tying premiums to income would weaken medicare politically over the long run, since people tend to be more supportive of universal social programs than of means-tested ones. medigap restrictions some medicare supplemental insurance (or "medigap") plans cover all of an enrollee's cost-sharing, insulating them from any out-of-pocket costs and guaranteeing financial security to individuals with significant health care needs. many policymakers believe that such plans raise the cost of medicare by creating a perverse incentive that leads patients to seek unnecessary, costly treatments. many argue that unnecessary treatments are a major cause of rising costs and propose that people with medicare should feel more of the cost of their care to create incentives to seek the most efficient alternatives. various restrictions and surcharges on medigap coverage have appeared in recent deficit reduction proposals. one of the furthest-reaching reforms proposed, which would prevent medigap from covering any of the first $500 of coinsurance charges and limit it to covering 50 percent of all costs beyond that, could save $50 billion over 10 years. but it would also increase health care costs substantially for people with costly health care needs. there is some evidence that claims of medigap's tendency to cause over-treatment may be exaggerated and that potential savings from restricting it might be smaller than expected. meanwhile, there are some concerns about the potential effects on enrollees. individuals who face high charges with every episode of care have been shown to delay or forgo needed care, jeopardizing their health and possibly increasing their health care costs down the line. given their lack of medical training, most patients tend to have difficulty distinguishing between necessary and unnecessary treatments. the problem could be exaggerated among the medicare population, which has low levels of health literacy. vision coverage the build back better legislation was passed in congress in november 2021, and adds hearing services subject to medicare part b deductible and 20% coinsurance beginning in 2023. the initial proposal of this bill also aimed to address gaps in medicare such as dental and vision coverage, however both services were removed following objections in the senate. a study performed by urban institute showed that medicare enrolees spend more on routine vision services ($8.4 billion) than routine hearing services ($5.7 billion), of which $5.4 billion and $4.7 billion were spent out of pocket respectively. in addition, nearly 1 in 3 medicare beneficiaries used vision services annually, and averages a spending of $411 per person; as such, the impact of expanding medicare to include vision services would benefit many people. of note, there is an income gradient seen in those who utilize vision services and a severe unmet needs for these services in those with lower incomes. enrolees below the federal poverty level spent $190, whereas those 400% above the level spent $465; and a likely trend that far fewer non-hispanic black and hispanic beneficiaries use and spend on vision services— which is in keeping with the trend seen with hearing aids. legislative oversight the following congressional committees provide oversight for medicare programs: senate senate committee on appropriations subcommittee on labor, health and human services, education, and related agencies senate budget committee senate committee on finance senate committee on homeland security and governmental affairs subcommittee on oversight of government management, the federal workforce, and the district of columbia senate committee on health, education, labor and pensions subcommittee on federal financial management, government information, and international security subcommittee on primary health and aging senate special committee on aging house house committee on appropriations subcommittee on labor, health and human services, education, and related agencies house budget committee house committee on energy and commerce subcommittee on health subcommittee on oversight and investigations house small business committee house committee on ways and means subcommittee on health joint joint economic committee