HS 104B - American Health Care System

Fall 2014

Friday, 2:00 PM – 3:50 PM

Olin Sang 101

Professor Stuart H. Altman, PhD

Teaching Fellows:

Andrew Wilson ()

Katherine Fillo ()

Caroline Logan ()

Julie Johnson ()

Purpose of the Course:

This course will examine and critically analyze the United States health care system, emphasizing the major trends and issues that have led us to where we are today. In addition to providing a historical perspective, this course will establish an economic, political, and social context for analyzing the current approaches to health care financing, delivery, and reform. While the course will focus on the U.S. health care system, the systems of other nations will be reviewed for comparison. Several sessions will focus on the needs of specific populations.

Course Requirements:

Attendance isrequired at the weekly two-hour lecture on Friday afternoons from 2:00 to 3:50 p.m. and for a 50-minute group discussion section to take place at scheduled times to be determined at the onset of the course. There will be an in-class mid-term, an in-class final examination, and a 10-page policy paper that focuses on a specific health policy question. The final grade will be based on the following:

Mid-term Exam (Oct. 17th)30%

Policy Paper Narrative Outline (Nov. 7st) 5%

Policy Paper (Dec 5th)15%

Final Exam (TENTATIVE: Dec 18th, 1:30-4:30 p.m.)30%

Discussion Section Participation20%

Late Policy:

Assignments are due by 11:59 P.M. on the dates noted in the syllabus. A late assignment will automatically receive a 5-point deduction for the first day. For each additional day the assignment is late, 1 point will be deducted. If an assignment is more than one week late without permission from your section TA, you will receive no credit for the assignment.

Discussion Section Participation

The discussion section will be graded based on two criteria: 1) attendance and 2) participation, including engagement with readings and class discussions and activities. To earn full credit for discussion section participation, students must not have any unexcused absences and must be actively engaged with the class material.

Students with Disabilities

If you are a student who needs academic accommodations because of a documented disability,please contact your section TA and present them with your letter of accommodation as soon as possible.If you have questions about documenting a disability or requesting academic accommodations, you should contact Beth Rodgers-Kay in Academic Services (x6-3470 or ). Letters of accommodation should be presented at the start of the semester to ensure provision of accommodations. Accommodationscannot be granted retroactively.

Statement on Academic Integrity:

Brandeis University’s Rights and Responsibilities states:

Every member of the University community is expected to maintain the highest standards of

academic integrity. A student shall not submit work that is falsified or is not the result of the

student’s own effort. Infringement of academic honesty by a student subjects that student to serious penalties, which may include failure on the assignment, failure in the course, suspension from the University or other sanctions (see Section 21). A student who is in doubt regarding standards of academic honesty in a course or assignment should consult the faculty member responsible for that course or assignment before submitting the work. A student’s lack of understanding is not a valid defense to a charge of academic dishonesty.

Please see Section 4 here ( for the full statement.

Required Books:

  1. Altman SH, Shactman D. Power, Politics, and Universal Health Care: The Inside Story of a Century-Long Battle: Prometheus Books; 2011 (referred to as “Altman & Shactman” throughout the syllabus).
  2. Bodenheimer TS, Grumbach K. Understanding Health Policy: A Clinical Approach. Sixth ed: McGraw-Hill Medical; 2012. (referred to as “UHP” throughout the syllabus)

Both of the books are available for e-readers and you can download a free Kindle Reading App, which can work on most devices (e.g., notebooks, smartphones, and tablets). See here:

**In addition to the required books, readings will be assigned from various resources on a weekly basis. These are all available on Latte.**

Week 1: August 29

The Factors that Influence Our Health Status: Coverage Matters and Who are the Uninsured?

Required Readings:

  1. Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC: National Academies Press, 2001. **Read Executive Summary and Chapter 1**
  2. Kaiser Family Foundation: Key Facts about the Uninsured Population 2013 Fact Sheet
  3. Woolf S, Braveman P. Where health disparities begin: the role of social and economic determinants--and why current policies may make matters worse. Health Affairs. 2011;30(10):1852-9.

**Monday, September 1: Labor Day - No classes**

Week 2: September 5

Insuring Americans from the Cost of Health Care: History of Private Insurance, Conventional Insurance/Fee-for-Service, and Managed Care/Capitation

Required Readings:

  1. UHP: Chp. 2, 3 (17-24), 4
  2. Kaiser Family Foundation. How Private Health Coverage Works: A Primer. April 2008.
  1. Managed Care: Altman & Shactman pp 35 to 39.
  1. Reinhardt, U.E. The real health care ‘war’ on the young. The New York Times. January 17, 2014.

**Thursday, September 11 is the last day to add classes**

Week 3:September 12

Medicare: How has it changed over time and can we support the Baby Boomers when they retire?

  1. Altman & Shactman: Chp. 5, 6, & 8
  2. Medicare Primer (2010):
  3. Medicare Prescription Drug Benefit Factsheet (2011):
  4. Medicare Advantage Factsheet (2011):

**Thursday, September 18 is the last day to elect pass/fail option for Fall 2013**

Week 4: September 19 (Prof. Michael Doonan)

The uninsured and the health care safety net: Medicaid and the Children’s Health Insurance Program (CHIP)

Required Readings:

  1. Altman & Shactman: Chp. 4 & 7
  2. Kaiser Medicaid and CHIP materials. Excellent summary resources available at:

a. Medicaid Primer (2013):

**Focus on the sections describing who and what Medicaid covers and how the program is financed**

b. Health Coverage of Children: The Role of Medicaid and CHIP (2012):

  1. Kaiser Family Foundation, What is Medicaid’s Impact on Access to Care, Health Outcomes, and Quality of Care? Setting the Record Straight (August 2013):
  2. Lowrey, A. “Oregon Study Shows Benefits, and Price for Newly Insured” NY Times Published 22 June 2012. Available:

**Tuesday, September 23: Brandeis Thursday**

**Thursday, September 25: Rosh Hashanah - No Classes**

Week 5: September 26

**ROSH HASHANAH - NO LECTURE**

Week 6: October 3

Health care reform I: The quest for universal coverage: Failed attempts, Obama’s success, and the decision of the Supreme Court

Required Readings:

National Health Reform

  1. Altman & Shactman: Prologue, Forward, Chp. 1-3 (Part I), and Chp. 11-18 (Part IV)
  2. Kaiser summary of health care reform:
  1. Kaiser Family Foundation, Getting Ready for Obamacare (animated video):
  1. Where the States Stand on Medicaid Expansion:
  1. Altman, D. A Tale of Two Siblings, the ACA and the Supreme Court. The Huffington Post (July 22nd, 2014).
  1. Krugman, P. Stealth Singer Payer. The New York Times (July 30, 2014).

Massachusetts Health Reform

  1. Kaiser Family Foundation. Massachusetts Health Care Reform: Six Years Later. May 1, 2012:

**Thursday, October 9: Sukkot - No Classes**

Week 7: October 10

Health care reform II: The structure of the U.S. health care delivery system, how it can be restructured, and proposals included in health care reform to change the health care delivery system

Required Readings:

  1. UHP: Chp. 5 & 6
  2. Kaiser summary of health care reform:
  1. Emanuel E. Why accountable care organizations are not 1990s managed care redux. JAMA (Chicago, Ill). 2012;307(21):2263-4:
  2. Rittenhouse DR, Shortell SM, Fisher ES. Primary Care and Accountable Care – Two Essential Elements of Delivery-System Reform. 2009 NEJM 361: 2301 – 2303.

Week 8: October 17

**MID-TERM EXAM**

The Mid-term Exam will cover material from Classes 1-7 only. Material from Classes 9-13 will be on the Final Exam.

Review sessions for the Mid-term will be held during the prior week (Oct 13th-Oct 16th). The specific times and locations are TBD and will be posted on LATTE.

Week 9: October 24(Prof. Dolores Acevedo-Garcia)

Health and health care disparities

Required Readings:

  1. **Review**Woolf S, Braveman P. Where health disparities begin: the role of social and economic determinants--and why current policies may make matters worse. Health Affairs. 2011;30(10):1852-9.
  2. Woods, E.R., Bhaumik, U. Sommer, S.J., Ziniel, S.I………Nethersole, S. Community Asthma Initiative: Evaluation of a quality improvement program for comprehensive asthma care. Pediatrics. 2012;129(3):465-472.
  1. Agency for Healthcare Research and Quality, National Healthcare Disparities Report - 2012

a. Chapter 10, Priority Populations: AND

  1. Kaiser, Health Reform and Communities of Color – Implications for Racial and Ethnic Health Disparities (September 2010):

Week 10: October 31

How We Pay for Health Care and Proposed Changes to the Payment System

Required Readings:

  1. UHP: Chp. 4 (Review)
  2. Culter D, Sahni N. If Slow Rate of Health Care Spending Growth Persists, Projections May be Off by $770 Billion. Health Affairs 2013; 32(5): 841-50.
  3. Korda H, Eldrige G. How Can We Bend the Cost Curve? Payment and Incentives and Integrated Care Delivery: Levers for Health System Reform and Cost Containment. Inquiry 2011; 48: 277-287.

Week 11: November 7

**ASSIGNMENT DUE: Your policy paper narrative outline must be emailed to your section TA by 11:59 p.m. today. Specifics will be discussed in your section**

The U.S. health care workforce: Issues in the supply and distribution of physicians, nurses, and physician assistants

Required Readings:

  1. UHP: Chp. 7
  2. Cooper, RA. “Weighing the Evidence for Expanding Physician Supply,” Annals of Internal Medicine, 141; 705-714, 2004.
  3. Goodman, D, & Fisher, E., “Physician Workforce Crisis? Wrong Diagnosis, Wrong Prescription,” NEJM, April 17, 2008.

Optional Readings:

APHA Issue Brief on ACA’s Public Health Workforce Provisions. June 2011:

**Wed, November 12 is the last day to withdraw from a course with a “W” on your transcript**

Week 12: November 14(Dr. Samuel Thier)

Health care quality and the role of public health in the U.S.

Required Readings:

  1. Berwick, Donald M. Escape Fire. In Eleventh Annual National Forum on Quality Improvement in Health Care. 1999. New Orleans, LA.
  2. National Institutes of Health, Evaluating the Quality of Health Care:

**For Further Reading (Optional)**

  1. Donabedian, Avedis. The Quality of Care: How Can it be assessed. Journal of the American Medical Association, 1988: 260(12): 1743-1748.
  2. Frieden, T.R. A framework for public health action. Am J of Public Health, 2010; 100(4):590-595.
  3. Chassin M.R., & Loeb, J.M. The Ongoing Quality Improvement Journey: Next Stop, High Reliability. Health Affairs 30 (4): 559 – 568.

Week 13: November 21

The influence of medical technology on the U.S. health care system: Prescription drugs as a case study and the use of comparative effectiveness research to evaluate medical technology

Required Readings:

  1. Kaiser Family Foundation, How Changes in Medical Technology Affect Health Care Costs (March 2007):
  2. New York Magazine, The Cost of Living. (October 2013):
  3. Blumenthal, D and Squires, D. Drugs and Dollars. The Commonwealth Fund (July 2014).
  4. Kaiser Family Foundation, Prescription Drug Trends (May 2010):

Week 14: November 28

**THANKSGIVING BREAK: NOV 26-NOV 30 – NO CLASS ON NOVEMBER 28**

Week 15: December 5

**ASSIGNMENT DUE: Your policy paper must be emailed to your section TA by 11:59 p.m. today. Specifics will be discussed in your section**

Can we learn from the health financing and delivery systems of other countries?

Required Readings:

  1. The Commonwealth Fund. Explaining High Health Care Spending in the United States (May 2012):
  2. The Commonwealth Fund. Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally (June 2014):

**For the following readings, choose ONE of the following countries to study: Canada, United Kingdom, Germany, or Israel**

*Germany, United Kingdom, and Canada*

  1. UHP: Chp. 14
  2. The Commonwealth Fund, Health Care System Profiles (November 2013):

*Israel*

  1. Myers-JDC-Brookdale Institute, Healthcare in Israel for U.S. Audiences (January 2011):

**Monday, December 8: Last day of classes**

**FINAL EXAM**

TENTATIVE: December 18, 1:30-4:30 p.m.

The Final Exam will draw heavily from the material of classes 9-15. However, questions will build off of material from before the mid-term (classes 1-7).

Review sessions for the Final will be held during the prior week (Dec 13th-Dec 17th). The specific times and locations are TBD.

Resources for Students

Additional/Supplemental Readings for Each Class

See the “Additional Supplemental Readings – Fall 2013” document posted in Latte. Use these readings to dig further into topics that interest you. This is good starting pointto begin your search for potential policy brief topics.

Health Policy References

Use these resources to stay up-to-date on current health policy debates, opinions, and research. They can also be a good place for generating paper topic ideas.

Academic Journals (available through Brandeis e-journals):

Health Policy and Health Services Research

  1. Health Affairs
  2. Milbank Quarterly
  3. Medical Care
  4. Health Services Research
  5. Journal of Health Politics, Policy, and Law
  6. Journal of Health and Social Policy
  7. Health Economics
  8. Quarterly Journal of Economics
  9. Econometrica
  10. Journal of Health Economics
  11. New England Journal of Medicine
  12. Journal of the American Medical Association
  13. The American Journal of Managed Care
  14. Medical Care Research and Review
  15. Journal of General Internal Medicine
  16. Journal of Health Care for the Poor and Underserved

Public Heath and Sociology & Psychology of Health and Illness

  1. American Journal of Public Health
  2. American Journal of Health Promotion
  3. Sociology of Health and Illness
  4. Social Problems

Web Resources (Think tanks, blogs, etc.):

  1. The Kaiser Family Foundation:
  2. Kaiser Health Reform Source. Available from:
  3. Health Care and Health Care Reform Terms and Definitions:
  4. Kaiser Family Foundation, Health Reform Glossary (not necessarily specific to health care reform):
  5. Kaiser Family Foundation, Widely Used (Medicaid Care Delivery and Financing) Terms (again, not necessarily specific to Medicaid):
  6. Blue Cross Blue Shield of Massachusetts, Glossary (might include some technical insurer terms):
  7. The Commonwealth Fund:
  8. Search within topic areas:
  9. Search within innovations (might be good to think about options for your policy briefs):
  10. The Robert Wood Johnson Foundation:
  11. Health Policy Connection:
  12. Harvard Kennedy School, Think Tank Search:
  13. Urban Institute:
  14. Brookings Institution:
  15. Brookings Institution, Engelberg Center for Health Care Reform:
  16. Center on Budget and Policy Priorities:
  17. The Cato Institute:
  18. Centers for Medicare and Medicaid Services:
  19. Center for Medicare and Medicaid Innovation:
  20. Agency for Healthcare Research and Quality:
  21. Centers for Disease Control and Prevention:
  22. Health Affairs, Health Policy Briefs:
  23. Princeton Conference XVII. Where do we go from here? The Future of Health Reform:
  24. The Incidental Economist: Bridges health care research and policy.
  25. New York Times Economix Blogger Dr. Uwe Reinhardt (health care topics):
  26. Boston Globe White Coat Notes:
  27. Project Millenial: A very good blog about health care policy written by “Millenials”.

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