Earlier this month, Medicare began allowing private insurers and other organizations that are offering prescription drug plans to older Americans to begin marketing their plans. Today, the marketing onslaught is in full swing. As the Medicare prescription drug benefit gets under way, there is already one clear winner: character actors "of a certain age" who are blanketing the airwaves. Not to be outdone, PacifiCare has dusted off old episodes of "I Love Lucy" and added digitally-altered Medicare themes. The government's marketing campaign asks America to "Pull up a chair. We've got something good to talk about."

Do we really? In spite of this packaging, the Medicare prescription drug benefit remains at its base an overly expensive and unduly complicated way to address a real social need. But as the full implementation of the benefit draws near, some features are coming into focus. What's promising? What isn't? Here's a quick summary:

The Good:

• Previous efforts to get private insurers to expand their participation in Medicare have been a debacle. Under the Medicare+Choice program, launched in 1997, private managed care plans quickly pulled up stakes and were reluctant to enter rural areas. Thus far, to almost everyone's surprise, insurers have been following the Field of Dreams model: the program was built, and they have come. No state, even sparsely populated Alaska, has fewer than eleven drug plans. States such as California and New York feature more than forty choices.
  
  
• Premiums are on average about 14 percent lower than anticipated. Every state in the continental United States will have at least one drug plan with a monthly premium below $20. This is good news for beneficiaries, especially if it means that savings that insurers and their benefits managers have been able to wrest from drug manufacturers are being passed on. In large part the low premiums reflect plan competition over initial market share and their eventual survival in the marketplace. What's the tradeoff for low premiums? Usually incredibly complicated benefit structures with different rules about deductibles, co-payments, and which drugs are covered.
  
  
• As of late September, about 3 million applications had been received by the Department of Health and Human Services by individuals who seek to qualify for low-income subsidies under the drug benefit. Officials think that about 15 million Americans might qualify for assistance. About half of these will automatically be enrolled by managed care organizations. It isn't clear how many of these applicants will actually be eligible, but the numbers are promising. Low-income seniors and disabled Americans receive by far the most relief under the new coverage. According to a recent study by PriceWaterhouseCoopers, beneficiaries with incomes of $14,500 or less (150 percent of the federal poverty level) will save 90 percent in out-of-pocket costs under the new coverage.
  
  
• The efforts toward beneficiary education have been extensive and energetic, if not always accurate or effective. Humana is spending $80 million on its outreach efforts, including a fleet of 10 RVs that made almost 500 stops around the country. Aetna plans to spend about $50 million, and other companies are dedicating substantial amounts. The federal government is spending half a billion dollars and has designated over 9,000 employees to answer questions about the benefit.

The Bad:

• Even though the efforts at educating beneficiaries have been strong, they have been plagued by troubling glitches. A government ad that ran nationally in Parade magazine wrongly stated that low-income beneficiaries could join any freestanding drug plan without paying an additional premium. After the government released its online plan comparison feature last week—itself well behind schedule—it failed to include the prices plans will charge for specific drugs. This makes it difficult or impossible for older Americans to make educated choices about whether to join a plan, or which one to select.
  
  
• Medicare beneficiaries are still reluctant to sign up. A Gallup poll released in early October showed that over half of Medicare beneficiaries didn't plan to sign up for a prescription drug plan. Fewer than a quarter said that they would definitely join the program. If you think the benefit is simply a disaster from the get-go, this isn't such a bad thing. But if older Americans don't sign up in the expected numbers, or if the majority of those who do sign up have high drug costs, premiums will rise, plans will lose leverage with drug manufacturers, and the whole program will fall flat. (Enrollment in Medicare managed care plans will probably grow as drug-only plans collapse, which may have been the underlying expectation in the first place.) Predictably, the media has been playing up the angle that Medicare beneficiaries are "dazed and confused" by the benefit. But what matters ultimately is whether seniors and disabled Americans grumble and sit on their hands or complain and eventually join up.

The Ugly:

• Beneficiaries who sign up for a drug plan after May 15, 2006 will face substantially higher premiums. (The promotional material for the benefit refers, somewhat euphemistically, to the need to join a plan to get "peace of mind." The punitive aspect has been deemphasized.) While the penalty is wholly legitimate as a matter of benefit design, it is sure to cause consternation among beneficiaries. Medicare's voluntary Part B, which covers physician and other services, has a similar built-in premium penalty. However, the default option for Part B is toward being enrolled rather than opting out (the Part B premium is automatically deducted from an eligible beneficiary's Social Security check unless stipulated otherwise). The drug benefit has the opposite design.
  
  
• On January 1, 2006, about seven million "dual eligibles" who qualify for both Medicare and Medicaid will be switched from their existing Medicaid coverage into the new Medicare plans. This turnover is fraught with potential problems. Most troubling is the prospect that some of these poorer beneficiaries will find that a drug they need isn't covered under their new plan.
  
  
• Beneficiaries are likely to be tempted to join drug-only plans to take advantage of posted low premiums, only to find that they have unwittingly given up their comprehensive managed care plan that offers full Medicare benefits. Under current rules, they will find it difficult to rejoin their earlier plan.
  
  
• The massive education effort simply underscores the unwieldiness and unnecessary complication of the benefit. As it is panning out in practice, the benefit represents choice overload at its worst. United HealthCare, for instance, in partnership with CVS pharmacy, has released a Show-Me Guide to the drug benefit. It is truly state-of-the-art: careful, thorough, and well-written. It is translated into seven languages, including Russian, Vietnamese, and Tagalog. It also runs to 24 pages and features a three-page glossary. Each hypothetical choice requires selecting among multiple options. Conscientious newspaper efforts to explain the benefit fall into the same unavoidable trap of being unable to do so in simple yet accurate terms.
  
  
• The traditional Medicare benefit didn't need extensive marketing because its basic structure (from the beneficiary's standpoint) was straightforward and its advantages clear. The new Medicare drug benefit fails this test. By contrast, Julie Goon, the director of the national Medicare Outreach campaign, touts the choice available under the new benefit: "If you want to make a decision based on the cost of a plan, there are plans that are very inexpensive, there are plans that cost more, there are different ways to do cost sharing. If you are looking for coverage in the coverage gap, there are plans that provide coverage for both generic and brand name drugs in that coverage gap. There are plans with low or no deductibles. So whatever works for a beneficiary, we have been trying to provide that kind of choice for them." But if you want simplicity, stability, and ease of enrollment, you have definitely come to the wrong place.

Leif Wellington Haase is a senior program officer and Health Care Fellow at The Century Foundation.