Social Work 561

Health Care Policy/Services: Inequalities and Development

Fall, 2005

Professor Gunnar Almgren

Class Meeting Times: Fridays 9:30 AM – 12:20 PM, SSW 26

Office: SW 127L

Office Hours: Monday 12:30-1:30 PM or by appointment Phone: 685-4077, e-mail mukboy@u.washington.edu

Web Homepage: http://faculty.washington.edu/mukboy/home/almgren.htm

I. General Course Description

The intent of this course is to acquaint future social work professionals in health care with the organization of the U.S. health care system in terms of policy and services, and the historical development and current structure of health care policy at the state and national level. Throughout the course, health care policies, services, and differential access to health and health care will be examined through alternative social justice frameworks and other contrasting ideological perspectives (e.g. neoconservative, political-economy).

The course begins by providing an overview of alternative frameworks for health policy analysis, followed by an historical review of the organization of American medicine, health care policy, and health care services from contrasting theoretical frameworks. Following a review of the major public programs and initiatives influencing the structure of health care services in the U.S., the content shifts to a more in-depth analysis of the role of race and social class in determining access to both health and health care. The final weeks of the course consider current national and local policy special issues in health care, including but not limited to prospects and strategies for health care reform.

The learning objectives of the course are as follows:

1) To be able to define, from a social justice perspective, the strengths and weaknesses of the current state of health care and health care policy in the United States.

2) To be able to describe, in general terms, the historical development of the mixed private and public model of health care in the United States and the emergence of the medical industrial complex.

3) To have a general comparative grasp of the U.S. health care system in terms of its institutional structures, organization of services, utilization, and outcomes relative to other developed nation states.

4) To be able to describe the essential reasons why the current structure of health care and health care financing in the United States promotes and contributes to diminished access to health care for the poor and near poor.

5) To be able to define key managed care concepts and trends, as well as the interdependent relationship between the corporate transformation of health care and the maintenance of systems of social stratification.

6) To have essential knowledge concerning the policies, regulations/laws, and publicly sponsored entitlements that provide the policy structure for social work practice in health care.

7) To afford each student the opportunity to engage in a learning assignment that builds upon their knowledge base in areas specific to their individualized learning plan for the advanced curriculum.

II. Readings, Learning Assignments and Grading

Readings. In order to strike a balance possible between availability of course material and prohibitive expense, I have used a combination of a softcover text and a list of E-Reserve Readings. Please note that the e-reserve readings are organized in electronic weekly folders (simply click on the class week to access the required readings). Although some of the readings assigned for the course may appear dated, all are selected very deliberately for their currency, significance, and relevance to health care policy. From time to time, I will also recommend source materials available on the internet. The required texts is:

Bodenheimer and Grumbach. Understanding Health policy : A Clinical Approach. New York : London : Lange Medical Books/McGraw-Hill, 2004. Available through University Bookstore at $34.95

Although the assigned readings for the first class session do not need to be read in advance, it is expected that students will have read the assigned readings in advance of all other class sessions. You will probably find the readings vary greatly to extent that they are easy or difficult to grasp. The most informative readings are sometimes conceptually abstract and require close analysis from the reader. The best advice is to avoid trying to read all of the assigned articles in one sitting and be willing to bring up points that seem confusing during class discussion. There is a tremendous amount of material related to health care policy, and I have endeavored to be selective and keep the expectations reasonable and consistent with graduate level work.

A special note on textbook readings: The organization of the Bodenheimer and Grumbach text corresponds with the content and structure of the course fairly well, but not perfectly. I have tied the content of the chapters assigned to each week’s main topics as much as possible, but students may simply wish to simply read the whole book from beginning to end in the first weeks of the course. The book is very clear and modest in length, so this is very doable.

Internet Resources: Over the past few years, various organizations concerned with health care policy have established websites for the dissemination and exchange of information and commentary. You will find on my instructional website several health policy links that collectively address many of the issues of core relevance to health policy.

Learning Assignments and Grading

Assignment #1 (20% of Grade)

Student reading group participation and facilitation. Students will be divided into reading groups during the first class meeting, and a minimum of 30 minutes of each class session will be devoted to discussions of the readings. In addition to general attendance and participation, each student will be responsible for the facilitation of at least one reading group session. Facilitation of a reading group session will require that you read the assignment well in advance, prepare critical questions and general points for your fellow students to consider as they read the material, and then develop a set of general questions, observations and points of debate that will contribute to a lively and informed discussion. The grade assigned will be based on a peer evaluation of your participation and facilitation over the course of the quarter.

Assignment #2 (35% of Grade)

Option #1

Policy Treasure Hunt. This assignment enables to student to learn about policies, regulations, laws, and publicly sponsored entitlements that provide the essential policy structure for social work practice in health care. Students will be given a set of questions that arise in five “example” cases, and students must answer all questions correctly on at least four of the cases to receive a minimum grade of 3.5. For a grade of 3.7 for this assignment, you must select and answer the questions on all five cases. A grade of 4.0 will be awarded on the basis of a brief summary of the health care policy implications to be drawn from your investigation of all five cases. Although I will be available to offer some general guidance to resources to answer the questions, you must primarily rely on your own investigatory skills. You can share policy resource information with each other, but you must write your own paper. The typical answer to most cases would not exceed one double-spaced page, although at least one case is more complicated and requires a more extensive response.

Option #2

NASW White Paper. This is brief (roughly 10 double-spaced) paper on some aspect of health care policy/health care services that is both relevant to your own interest and to the social work profession. The paper should at a minimum identify an issue related to health care policies or services, provide the relevant background information for solid understanding of the issue and the important questions, and then evaluate a set of policy alternatives in accordance with an explicit social justice framework. Examples of this might be the quality and availability of health care services to Native Americans, the balance between respect for cultural norms and the rights of women, whether children in foster care fair better under fee-for-service Medicaid or managed care, and the extent to which the assets of elderly should be subject to Medicaid eligibility for long term care. Papers that are awarded a 3.7 or higher will be cogent, thoughtful, and reflect the author’s careful research of the issue(s).

Assignment #3 (45% of Grade)

Framing the Policy Agenda and Strategy for Health Care Reform. This will be a medium length (circa 15 page) paper that outlines the basis and specifics of policy a agenda for national health care reform, as well as a political strategy to transform your policy agenda to de facto policy. This paper should first explicitly identify the features of a “just” approach to the problem of health and health care in accordance with an explicit theory of social justice, and link that to your policy agenda (e.g. a five point plan for eliminating the uninsured population). Your political strategy may take any number of approaches, (e.g. the organization of national coalitions, the creation of a populist movement, a federalized state-by-state approach, or a combination of strategies that has clear central cohesion). Your policy agenda and political strategy needs to be based on a realistic appraisal of the political environment, lessons from historical successes and failures, and potential obstacles and allies, and the health care policy agenda of the Bush administration. A good way to frame this paper is the kind of policy and political action proposal you might submit as the staff consultant to a politician or political action group.

Grading standards applied in this course will be consistent with those described in the University Handbook (Chapter 11, Section 1). Written assignments that are graded at or above a 3.7 will need to be completed by the due date, reflect high standards of organization, include consideration of the key issues, and demonstrate graduate level critical thinking skills. Since a significant part of the learning objectives for this course are fulfilled through classroom discourse, 20% of the course grade will reflect the instructor’s evaluation of the student’s availability to the class and a quality of participation in classroom discussions that is reflective of preparation and critical thinking (as described in Assignment#1).

Assignment Due Dates

Assignment	% of Grade	Due Date
#1 Reading Groups	20%	Peer Rating Sheets Due Dec. 14^th
#2 Treasure Hunt/White Paper	35%	Due December 2^nd
#3 Health Care Policy Agenda/Political Strategy Paper	45%	Due December 14^th

During the week of November 28th, I will accept drafts of the final paper for review and comment. I will return the drafts with my comments to students by December 12^th so that students will have one week to incorporate any suggested revisions.

Students with Disabilities

The School of Social Work and the University at large are committed to ensuring facility and program access to students with either permanent or temporary disabilities through a variety of services and equipment. The Disability Resources for Students Office (DRS) coordinates academic accommodations for enrolled students with documented disabilities. Accommodations are determined on a case-by-case basis and may include classroom relocation, sign language interpreters, recorded course materials, note taking, and priority registration. DRS also provides needs assessment, mediation, referrals, and advocacy as necessary and appropriate. Requests for accommodations or services must be arranged in advance and require documentation of the disability, verifying the need for such accommodation or service. If you would like to request academic accommodations due to a disability, please contact DRS Office 448 Schmitz 206-543-8924 (V) 206-543-8925 (TTY). If you have a letter from Disabled Student Services indicating you have a disability that requires academic accommodations, please present the letter to me so the two of us can discuss the accommodations you might need for the class.

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Weekly Class Schedule

Week 1 September 30

Course Overview and Alternative Frameworks for Health Policy Analysis

Bodenheimer and Grunbach, Chapter 1

E-reserve readings:

Norman Daniels. Justice, Health and Health Care. In Rhodes, Battin and Silver (eds.) Medicine and Social Justice. Oxford Univ. Press: 2002.

John Rawls. Fundamental Ideas. In Rawls Justice as Fairness: A Restatement. Harvard Univ. Press: 2001.

Ruger (2004). Health and Social Justice. The Lancet 364: 1075-80.

Week 2 October 7

From Science and Free Enterprise to Corporate For-Profit Care: The Historical Evolvement of the U.S. Health Care System

Bodenheimer and Grumbach: Chapters 2 through 4 &16

E-reserves:

Shi and Singh. The Evolution of Health Services in the United States. Delivering Health Care in the United States: A Systems Approach. Aspen Publishers 2001.

Almgren, Kemp and Eisinger (2000). The Legacy of Hull House and the Children’s Bureau in the American Mortality Transition. Social Service Review (74 (1): 1-27.

Week 3 October 14

The ABC’s of Health Care Finance and the Contemporary Organization of Health Care Services in the U.S.

Bodenheimer and Grumbach: Chapters 5 through 9 and 17.

E-reserves:

Anderson et al (2003). It’s the Prices Stupid: Why the United States is So Different from Other Countries. Health Affairs 22 (3): 89-105.

Heffler et ak (2004). Health Spending Projections Through 2013. Health Affairs 2004 Supplement: 79-93.

The World Health Organization World Health Report 2002: Statistical Annex.

Week 4 October 21

Segmented Disenfranchisement from Health and Healthcare: Examining the Influences of Social Inequalities on Health

Bodenheimer and Grumbach: Chapter 14

E-Reserves:

Marmot. (2001). The Influence of Income on Health.: Views of an Epidemiologist. Health Affairs 21 (2).

Key Facts: Race, Ethnicity and Medical Care. Henry T. Kaiser Foundation. June 2003.

Link and Phelan (1995). Social Conditions as Fundamental Cause of Disease. Journal of Health and Social Behavior. Supplemental Issue: 80-95.

Krieger (2001). A Glossary for Social Epidemiology. Journal of Epidemiology and Community Health 55:693-700.

Guest, Almgren and Hussey. (1998) The Ecology of Race and Socioeconomic Distress: Infant and Working Age Mortality in Chicago. Demography Vol. 35 (1) pp. 23-34.

Week 5 October 28

Special Issue Focus #1: The Graying of America: Biology, Technology and Medicare Reform

E-Reserves:

McKusick. (1999) Demographic Issues in Medicare Reform. Health Affairs 18 (1): 194-207.

Fuchs. (1999) Health Care for the Elderly: How Much and Who Will Pay for It. Health Affairs 18(1): 11-22.

Callahan (1996). Controlling Health Care Costs for the Elderly: Fair Means and Foul. New England Journal of Medicine 335 (10): 743-746.

Lawlor. A Medicare Parable: Technology and the Artificial Heart Story. Redesigning the Medicare Contract: Politics, Markets and Agency. University of Chicago Press: 2003.

Families USA. (2003) Out of Bounds: Rising Costs of Prescription Drugs for the Elderly. Families USA Publication No. 03-106.

Goozner. (2000) The Price Isn't Right. The American Prospect vol. 11 (20).

Medicare Drug Discount Card No Match for the Real Savings Obtained by Department of Veteran’s Affairs. Press Release June 2, 2004, Families USA.

*Centers for Medicare and Medicaid Services. Medicare and You 2006. CMS Washington D.C.: 2005.

**Medicare Drug Discount Cards: A Work In Progress” 7/28/2004 Kaiser Family Foundation, Washington, D.C.

*For those students unfamiliar with the basic benefits, eligibility criteria, and program options of Medicare.

**Optional

Week 6 November 4

Special Issue Focus #2: Long Term Care Policy

Johnson et al. Is Private Long Term Care Insurance the Answer? Center for Retirement Research Issue Brief No. 29, May 2005.

O'Brian and Elias (2004) Medicaid and Long Term Care. Kaiser Foundation, Washington D.C.

Policy Challenges Posed by the Aging of America. A discussion briefing prepared for the Urban Institute Board of Trustees meeting, May 20, 1998. (Highly recommended!)

Bodenheimer and Grumbach: Chapters 10 though 12

Week 7 November 18

Special Issue Focus #3: The Corporate Transformation of Health Care: Health as a Commodity

E-Reserves

Robinson. Bond-Market Skepticism and Stock Market Exuberance in the Hospital Industry. Health Affairs 21 (1): 104-117

Silverman, Skinner, and Fisher.(1999) The Association between For-Profit Hospital Ownership and Increased Medicare Spending. New England Journal of Medicine 341 (6): 420-426.

Bell (1996). Saving Their Assets: How to Stop Plunder at Blue Cross and Other Nonprofits. The American Prospect Vol 26: 60-66.

Jasso-Acquilar et al. (2004). Multinational Corporations and Health Care in the United States and Latin America: Strategies, Actions and Effects. Journal of Health and Social Behavior 45 (Special Issue): 136-157

Helms. (2000) Health Care a la Karl Marx. American Enterprise Institute Commentary.

Calfee (2003). The High Price of Cheap Drugs. The American Enterprise Institute Commentary.

*The Best Value in Medicine Today: How Prescription Drugs Account for a Fraction of the Health Care Cost Increases While Helping to Offset Other Health Care Costs. PhRMA Policy Papers June 2002.

Sprinkle (1997). Corporatism in Question: A Note on Managed Care. Report from the Institute for Philosophy and Public Policy: 1-9.

*Wynne, Michael. (2000) The Rise and Fall of Columbia HCA. The Corporate Health Care Homepage

*Readers are cautioned that there is no objective editorial review of content. Both are included to represent policy relevant public discourse.

Week 8 December 2

Special Issue Focus #4: Distributive Justice and Defining the Limits of Medical Intervention

E-Reserves

Fox R. and Swazey J. (1992). Leaving the Field. Hastings Center Report. September-October 1992 pp. 9-15.

Small. (2002) The Ethics of Life Expectancy. Bioethics 16 (4): 307-334.

Etzioni. (1991) Health Care Rationing: A Critical Evaluation. Health Affairs 10 (6): 88-95.

Millman and Roberts 2002 Organ and Issue Transplant Costs and Discussion. Milliman and Robertson Research Reports. (Review sections III and VI, as well as milestones summary).

Koch. (2005). The Challenge of Terri Schiavo: Lessons for Bioethics. Journal of Medical Ethics 31: 376-378.

*Cohen (2004) Negotiating Death: ADR and End-of-Life Decision-making. Harvard Negotiation Law Review. 9 Summer 2004:293.

*Almgren, Gunnar (1993). Living Will Legislation, Nursing Home Care, and the Rejection of Artificial Nutrition and Hydration: An Analysis of Bedside Decision-Making in Three States. Journal of Health and Social Policy 4 (3). Pp. 43-63.

Bodenheimer and Grumbach, Chapter 13

*Optional

Week 9 December 9

Special Focus Issue #5: Health Care Reform 2004: Examining the Strategic and Political Options for the Social Work Profession

E-Reserve Readings

Aaron and Butler. How Federalism Could Spur Bipartison Action on the Unisnusred. Health Affairs 2004 Supplement: 168-178.

Thorpe. The Medical Malpractice ‘Crisis’: Recent Trends and The Impact Of State Tort Reforms. Health Affairs Supplement: 20-31

Patterson and Cox (2001). How Social Workers Can Link Children to Free and Low Cost Health Insurance. Center on Budget and Policy Priorities Report.

Syme, Lefkowitz and Krimgold. (2002) Incorporating the Socioeconomic Factors Into U.S. Health Policy: Addressing the Barriers. Health Affairs 21 (2): 113-118.

Nichols et al. (2004). Are Market Forces Strong Enough to Deliver Efficient Health Care Systems? Confidence is Waning. Health Affairs 23 (2): 8-21.

Hock et al. (2005). Should the Emergency Department Be Society’s Health Safety Net? Journal of Public Health Policy 26 (3): 269-282.

Bodenheimer and Grumbach: Chapters 15 and 18