Social Work 528

Health Care Policy/Services: Inequalities and Development

Fall, 2007

Professor Gunnar Almgren

Class Meeting Times: Fridays 9:30 AM – 12:20 PM, SSW 38

Office: SSW 244A

Office Hours: Tuesday 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 providing 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 available at the following URL:
 
https://eres.lib.washington.edu/eres/coursepage.aspx?cid=2400&page=docs
 
 

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 a few 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 text is:

Gunnar Almgren. Health Care Politics, Policy and Services: A Social Justice Analysis. New York: Springer 2007. Available through University Bookstore at $60.00.

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.

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, with 30 minutes of each class session 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: Part 1 20% and Part II 25%)

Framing the Policy Agenda and Strategy for Health Care Reform. This assignment is structured as two segments of a single cohesive paper of medium length (circa 15 pages). The first section of the paper (comprising roughly one-half of the total length of the paper) will be handed in at mid-term, graded, and then returned with suggestions to be incorporated in the final full version of the paper due at the end of the term (see specific due dates below). The final full version of the paper will be comprised of the edited version of Part I of the paper and Part II of the paper.

Part I

This first part of the paper applies an explicit theory of social justice of the student’s choosing to the problem of health care. The required elements of this first part of the paper include:

1) a general description of the theory of justice selected that includes its core principles and arguments

2) a definition of what specific rights and claims pertaining to the provision of health care are derived from that theory

3) implications of the above for a “socially just” scheme or approach to the distribution of limited health care resources.

Although this part of the paper may draw upon the works of various scholars of social justice, the student’s synthesis of the arguments and implications is to be original.

Part II

This second part of the paper identifies an explicit health care policy agenda that is derived from the arguments presented in Part I, and then presents the main points of political strategy for the transformation of the proposed policy agenda to de facto health care policy. The required elements of this second part of the paper include:

1) point by point policy agenda that is explicitly linked to arguments made in Part I, specifically those arguments pertaining to the rights/entitlements to health care and a socially just approach to the distribution of limited health care resources

2) the core assumptions of a political strategy to translate the agenda to policy

3) the specific goals and action steps entailed in the political strategy

4) the major barriers/challenges pertaining to 3) above.

Note that your chosen 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 current presidential administration. A good way to frame this paper is the kind of policy and political action proposal you might submit as an elected official’s staff specialist on health affairs or as a consultant to a political action group.

Grading Standards

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. Much of the learning that takes place in this course is dependent upon completion of reading assignments and engagement in classroom discussions, for this reason Assignment I is a significant part of the overall course grade.

Assignment Due Dates

Note that all assignments are due by 5:00 P.M on the date identified, in hardcopy in the instructor’s mailbox. Due to the excessive time and expense involved in downloading dozens of student papers, copies submitted in electronic format will not be accepted unless agreed to on an individual basis in advance of the assignment’s due date.

Assignment	% of Grade	Due Date
#1 Reading Groups	20%	Peer Rating Sheets Due Dec. 12^th
#3 Part I -Framing the Policy Agenda and Strategy for Health Care Reform	20%	Due November 9^th
#2 Treasure Hunt/White Paper	35%	Due December 7^rd
#3 Part II -Framing the Policy Agenda and Strategy for Health Care Reform	25%	Due December 12^th

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. If you would like to request academic accommodations due to a disability, please contact Disability Resources for Students, 448 Schmitz, 206-543-8924/V, 206-543-8925/TTY. If you have a letter from the office of Disability Resources for Students indicating you have a disability that requires academic accommodations, please present the letter to me so we can discuss the

accommodations you might need for this class.

__________________________________________________________________

Weekly Class Schedule

Week 1 September 28

Course Overview and Alternative Frameworks for Health Policy Analysis

Text

Chapter 1 A Primer of Theories of Social Justice and Defining the Problem of Health Care

E-reserve readings:

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

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

Week 2 October 5

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

Text

Chapter 2 The Historical Evolvement of the U.S. Health Care System

E-reserves:

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 12

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

Text.

Chapter 3 The Contemporary Organization o Health Care Finance

Chapter 4 The Contemporary Organization of Health Care: Health Care Services and Utilization

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 (2005). Health Spending Projections Through 2014. Health Affairs 2005 W-5: 74-85.

The World Health Organization 2005 Statistical Annex. Access on line at http://www.who.int/whr/2005/annex/en/index.html.

Week 4 October 19

Segmented Disenfranchisement from Health and Healthcare: Examining Disparities in Health and in Health Care

Text

Chapter 6 Disparities in Health and in Health Care

E-Reserves

Banks et al. Disease and Disadvantage in the United States and in England. JAMA 295 (17) May 3, 2006: 2037-2045.

Anderson (2007). From 'Soak The Rich' To 'Soak The Poor': Recent Trends In Hospital Pricing.

Health Affairs 26 (3): 780-789

Halperin (2007) The poor, the Black, and the marginalized as the source of cadavers in United States anatomical education. Clinical Anatomy 20 (5): 489-495.

Berggren (2005). Unexpected Necessities — Inside Charity Hospital. New England Journal of Medicine 353 (15) October 13: 1550-1553.

Week 5 October 26

The Social Determinants of Disparities in Health

Text

Chapter 7 Social Epidemiology: Unraveling the Social Determinants of Disparities in Health

E-Reserves:

Marmot. (2001). The Influence of Income on Health.: Views of an Epidemiologist. Health Affairs 21 (2): 31-46.

Kawachi, Daniels, and Robinson (2005) . Health Disparities By Race And Class: Why Both Matter. Health Affairs 24 (2): 343-352.

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

** Optional Reading

Week 6 November 2

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.

Vladeck (1999). The Political Economy of Medicare. Health Affairs 18 (1): 22-36.

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.

Slaughter (2006). Medicare Part D — The Product of a Broken Process. New England Journal of Medicine 354 (22): 2314-2315.

Families USA (2006). Big Dollars, Little Sense: Rising Medicare Prescription Drug Prices. Families USA. Excerpt from Publication No. 06-104: 1-18.

*Centers for Medicare and Medicaid Services. Medicare and You 2007. CMS Washington D.C. Access at:

http://www.cms.hhs.gov/partnerships/downloads/10050%20-%20OR%20WA.pdf

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

Week 7 November 9

Special Issue Focus #2: Long Term Care Policy

Text

Chapter 5 Long Term Care of the Aged and Disabled

E-Reserves

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!) Access at : http://www.urban.org/publications/1000214.html

Week 8 November 16

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

E-Reserves

Robinson (2002). 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.

Jepsen (1997). The rise and fall (of Columbia HCA CEO). Modern Healthcare v27.n36 (Sept 8, 1997): pp30(7).

Week 9 November 30

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.

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.

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). Access at:

http://www.transplantliving.org/ContentDocuments/2002_Milliman_Report.pdf

Week 10 December 7

Special Focus Issue #5: Health Care Reform 2007: Examining the Strategic and Political Options for the Social Work Profession

Text

Chapter 8 Competing Agendas for Health Care System Reform: A Social Justice Critique

E-Reserve Readings

Aaron and Butler. How Federalism Could Spur Bipartison Action on the Uninsured. 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.

Blendon, R. J., Marttila, J., Benson, J. M., Shelter,M. C., Connolly, F. J.,&Kiley, T. (1994). The beliefs and values shaping today’s health reform debate. Health Affairs, 13(1), 274–284

Starr. What happened to welfare reform?. The American Prospect no. 20 (Winter 1995): 20-31