Health Policy and Politics in the U.S.
Professor Joseph White
MWF 10:30 a.m. – 11:20 a.m.
Draft Syllabus, July 29, 2005
Health care in the United States consumes 15 percent of the national economy. Medical services are of fundamental interest to all Americans, even or especially those who are too young or too frail to know what their interests are. Government is involved with health care in more ways than anyone can count – yet, in one basic way, American government does less about health care than the governments do in any other rich democracy.
These factors all make health an aspect of policy and politics that is worth studying both for its own significance and for what it tells us about American public policy and politics more generally. Three things stand out for me.
First, when we study health policy, we are forced to recognize how important government and public policy are. It’s not theoretical: it involves people living and dying, suffering or thriving.
Second, health policy, specifically national health insurance, is the great case of American exceptionalism. There is a lot of talk about how unusual America is, and our education and pension and police and environment and military policies do differ somewhat from those in other countries. But there is no other field in which the U.S. differs so greatly from all other comparable countries. Why?
Third, health policy particularly highlights an aspect of government that is easy to miss in the usual courses that focus on political decision-making. All governments (not just in the United States) that seek to use policy to influence health have to work through a wide range of institutions and individuals who are not part of government. These all have their own norms, values, powers and resources. The most important, by far, is the medical profession. Many public policies require that government affect individual behaviors, and that is often hard. Yet the challenges of dealing with the medical profession are an extreme case, and raise in the starkest form issues of government capacity: what governments can do.
This course is designed especially for two groups of students. One is political science students. The other is those who might choose careers in public health, medicine, or related fields. It may have a bit too much politics for one group, and a bit too much health policy for the other. I hope each will conclude that both aspects of the course are important and interesting.
Outline of the Course and its Objectives:
In the first half of the course we will focus on health policy itself. We will work to understand the extremely complex system of health care finance and delivery in the United States, and the extensive range of issues that people can raise if they want to improve the system. As a matter of political theory, this part of the course should give students a sense of how hard it is to defend simple notions about “politics” and “markets,” as well as how hard a task politicians and bureaucrats face in trying to meet our demands to make the system better. For those who expect to work in the health care system in some way, this should give you a more realistic sense of what you will be getting into.
In the second half of the course we will focus on the process of policy-making. That includes two themes: how people argue about policy, and a bit on how American political institutions are said to bias the outcome of those arguments. In addition to readings that provide a look at health care politics more generally, we will focus on a few specific issues, considering them both as examples of the challenges of the health field and the operation of the policy process.
The work for this course will include reading done by all students; a midterm exam onOctober 17; a final exam on December 13; and separate reports on supplementary reading, due in class on November 30. Undergraduates will be required to do one reading report, of a minimum of 2000 words. Graduate students will be required to read two supplementary books, both on the same policy topic, and complete a 3500 word report. They will also be required to lead any class discussion of their topic.
Grades for undergraduates will be based 25% on the midterm, 25% for the reading report, 40% for the final, and 10% for class participation.
Grades for graduate students will be based 25% on the midterm, 30% for the reading report, 35% for the final, and 10% for class participation.
To prepare for exams you may prepare, by yourself (no help from others please), and submit a one-page, double-sided summary of each class session’s reading prior to the beginning of that class. These summaries will be returned to you by the professor for use during the midterm, and collected afterwards so they can be returned to you again for the final. Only these notes can be used during the midterm or final exam. These summaries are not an official requirement of the course, therefore no “make up” or late summaries can be accepted after the beginning of the class session for which the readings were assigned.
All assigned readings should be done prior to the class for which they are scheduled, as they will be discussed on the indicated date.
Reading for all students will include two texts and a selection of articles. Some of the articles can be downloaded directly from public websites. Others will be placed on electronic and hardcopy reserve. There is virtually a third book (in volume) of articles that I have written. Those will be placed on the course blackboard site as well as in the library, but I will also arrange to create a reader of those articles if students so request, figuring that copyright on my own work should not be an issue.
The required texts for all students are:
Reading for all students will include two texts and a selection of articles. Most articles will be collected into a reader available for purchase, and also put on electronic reserve. A few should just be downloaded directly from their sources via the internet.
The required texts for all students are:
Thomas S. Bodenheimer and Kevin Grumbach. 2001. Understanding Health Policy: A Clinical Approach 4th ed. (Lange Medical Books)
John E. McDonough. 2000. Experiencing Politics: A Legislator’s Stories of Government and Health Care. (University of California Press)
The supplementary texts from which students will choose are listed at the end of this syllabus. Material from the class is listed below on the schedule of assignments.
Schedule of Assignments and Readings:
Section 1: The Financing and Organization of American Health Care
August 29: First class. Introduction and explanation of the course
August 31: Bodenheimer and Grumbach Chapter 1 (overview) and Chapter 2 (Paying for Health Care). Pages 1-14.
Sept 2: No class; instructor will be at American Political Science Association meeting.
Sept 5: No class, Labor Day
Sept 7: Bodenheimer and Grumbach Chapters 3, “Access to Health Care,” and 15, “National Health Insurance”. Pages 15-29, 158-166. Uwe E. Reinhardt, “The Mix of Public and Private Payers in the U.S. Health System.” In Alan Maynard ed., The Public-Private Mix for Health. Oxford, UK: Radcliffe Publishing, 2005. (This article had to be scanned in two parts; I’m not sure why. So I have given the library both parts for electronic reserve).
Sept 9: Bodenheimer and Grumbach, Chapter 4, “Reimbursing Health Care Providers,” and Chapter 5, “Capitation Payment in Managed Care.” Pages 30-45.
Sept 12: Bodenheimer and Grumbach, Chapters 6-7, “How Health Care Is Organized I and II.” Pages 46-68.
Sept 14: Bodenheimer and Grumbach, Chapter 8, “Painful vs. Painless Cost Control,” and Chapter 9, “Mechanisms for Controlling Costs,” pages 69-92.
Sept 16: Joseph White, “Targets and Systems of Health Care Cost Control.” Journal of Health Politics, Policy and Law 24:4 (August 1999).
Sept 19: National Academy of Social Insurance, Medicare and the American Social Contract. Chapters 1-3, pp. 1-67. Download from: http://www.nasi.org/publications2763/publications_show.htm?doc_id=54378
Students must select the book or books for their supplementary reading by this date.
Sept 21: Bodenheimer and Grumbach, Chapter 10, “Long-term Care.” Pages 93-101. Kaiser Commission on Medicaid and the Uninsured: “Medicaid: A Primer.” Downloadable from http://www.kff.org/medicaid/2248-index.cfm.
Sept 23: Uwe Reinhardt, “The mix of public and private payers in the U.S. health system.” from Alan Maynard ed. The Public-Private Mix for Health.
Sept 26: Joseph White, “National Health Care/Insurance Systems.” From International Encyclopedia of the Social and Behavioral Sciences, 4th ed. (2001). Mark V. Pauly, “Trading Cost, Quality, and Coverage of the Uninsured: What Will We Demand and What Will We Supply?” From Stuart Altman, Uwe E. Reinhardt, and Alexandra E. Shields eds., The Future U.S. Healthcare System: Who Will Care For the Poor and Uninsured? (Health Administration Press: 1998) Guest Speaker: Professor Deborah Stone!
Sept 28: Joseph White, “Three Meanings of Capacity: Or, Why the Federal Government Is Most Likely to Lead on Insurance Access Issues.” Journal of Health Politics, Policy and Law 28: 2-3 (2003).
Section 2: Medical Care, Health, and Quality
Sept 30: Bodenheimer and Grumbach, Chapter 11, “The Prevention of Illness” Pages 102-113.
October 3: Lawrence Gostin, “A Theory and Definition of Public Health Law,” from Gostin, Public Health Law: Power, Duty, Restraint. (University of California Press, 2000). Pages 3-22.
October 5: Bodenheimer and Grumbach, Chapter 12, “The Quality of Health Care,” Pages 114-128; Joseph White, “Choice, Trust, and Two Models of Quality.” Journal of Health Politics, Policy and Law 24:5 (1999).
October 7: GAO: “Medical Malpractice Insurance: Multiple Factors Have Contributed to Premium Rate Increases.” Testimony Before the Subcommittee on Wellness and Human Rights, Committee on Government Reform, House of Representatives. October 1, 2003. Download from: http://www.gao.gov/new.items/d04128t.pdf
October 10: GAO: “Medical Malpractice: Implications of Rising Premiums on Access to Health Care.” August, 2003. Pages 5-7 (Results in Brief), 12-30 (Implications for Access and Practice of Defensive Medicine), 53-55 (Research on Defensive Medicine). Download from: http://www.gao.gov/new.items/d03836.pdf. Kenneth E. Thorpe, “The Medical Malpractice ‘Crisis’: Recent Trends And the Impact of State Tort Reforms.” Health Affairs Web Supplement 21 January 2004, pp. 20-30.
October 12: Bodenheimer and Grumbach Chapter 13, “Medical Ethics and the Rationing of Health Care.” Pages 129-142. Joseph White, “Health Care at the End of Life” ms.
October 14: Bodenheimer and Grumbach, Chapter 17, “The Health Care Workforce,” and Chapter 18, “Conclusion: Tensions and Challenges.” Pages 176-189.
October 17: Midterm Exam
Section 3: The Health Care Policy Process
October 19: No reading assigned; Lecture by instructor.
October 21: McDonough, Introduction and Chapter 1. Pages 1-45. (What politics is)
October 24: Fall Break.
October 26: McDonough, Chapter 2. Pages 46-80. (Stories and argumentation) Joseph White, “Health Care Reform: What’s the Problem?” From Theodore R. Marmor and Philip R. DeJong eds., Ageing, Social Security and Affordability. (Ashgate: 1998).
October 28: McDonough, Chapter 3. Pages 81-118. (Understanding conflict)
October 31: McDonough, Chapter 4. Pages 119-157. (Interests).
November 2: McDonough, Chapter 5. Pages 158-196. (Representation).
November 4: McDonough, Chapter 6. Pages 199-236. (Change)
November 7: McDonough, Chapter 7. Pages 237-284. (Agenda-setting)
November 9: McDonough, Chapter 8. Pages 285-310. (Conversations and games).
November 11: McDonough, Chapter 9. Pages 311-322. (Conclusion).
November 14: Donald W. Light, “Ironies of Success: A New History of the American Health Care ‘System’”. Journal of Health and Social Behavior 2004, Vol. 45 (Extra Issue).
November 16: Deborah Stone, “The Doctor as Businessman: The Changing Politics of a Cultural Icon” From Mark A. Peterson ed., Healthy Markets? The New Competition in Health Care (Duke University Press, 1998)
November 18: Lawrence P. Casalino, “Unfamiliar Tasks, Contested Jurisdictions: The Changing Organizational Field of Medical Practice in the United States.” Journal of Health and Social Behavior 2004, Vol. 45 (Extra Issue).
November 21: Allen Schick, “How a Bill Did Not Become a Law.” In Thomas E. Mann and Norman J. Ornstein eds., Intensive Care: How Congress Shapes Health Policy. (American Enterprise Institute and The Brookings Institution: 1995).
November 23: Sven Steinmo and Jon Watts, “It’s the Institutions Stupid! Why Comprehensive National Health Insurance Always Fails in America.” Joseph White, “The Horses and the Jumps: Comments on the Health Care Reform Steeplechase.” Both from Journal of Health Politics, Policy and Law 20:2 (Summer 1995).
November 25: Thanksgiving Break.
November 28: Ronald Bayer, “Blood and AIDS in America.” From Eric Feldman and Bayer eds., Blood Feuds: AIDS, Blood, and the Politics of Medical Disaster (Oxford University Press, 1999).
November 30: Class discussion on National Health Insurance supplementary reading.
Reading Reports Due Today
December 2: Class discussion on tobacco control supplementary reading.
December 5: Class discussion on Medicare supplementary reading.
December 7: Class discussion on other supplementary readings.
December 9: Concluding lecture and discussion.
Final Exam: DECEMBER 13, 9:00 a.m. – 11:30 a.m.
Suggested Books for Supplementary Reading Reports:
The books on this list are definitely acceptable. Students may request permission to report on another book, but consent is at the discretion of the instructor.
Topic 1: National Health Insurance.
Jacob S. Hacker. 1997. The Road to Nowhere: The Genesis of President Clinton’s Plan for Health Security. Princeton, NJ: Princeton University Press.
Haynes Johnson and David S. Broder. 1996. The System: The American Way of Politics at the Breaking Point. Boston: Little, Brown & Company.
Rick Mayes. 2004. Universal Coverage: The Elusive Quest for National Health Insurance. Ann Arbor: University of Michigan Press.
Theda Skocpol. 1996. Boomerang: Health Care Reform and the Turn Against Government. New York: W.W. Norton & Co.
Topic 2: Medicare
Theodore R. Marmor. 2000. The Politics of Medicare, 2nd ed. New York: Aldine de Gruyter.
Jonathan Oberlander. 2003. The Political Life of Medicare. Chicago: University of Chicago Press
David G. Smith. 2002. Entitlement Politics: Medicare and Medicaid, 1995 – 2001. New York: Aldine de Gruyter.
Topic 3: Tobacco
Martha A. Derthick. 2004. Up in Smoke: From Legislation to Litigation in Tobacco Politics 2nd ed. Washington, DC: CQ Press
David A. Kessler. 2001. A Question of Intent: A Great American Battle With a Deadly Industry.New York: Public Affairs.
Michael A. Pertschuk. 2001. Smoke in Their Eyes: Lessons in Movement Leadership from the Tobacco Wars. Nashville: Vanderbilt University Press.
Topic 4: AIDS and Public Health
Christopher H. Foreman, Jr. 1994. Plagues, Products & Politics: Emergent Public Health Hazards and National Policymaking. Washington, DC: The Brookings Institution.
Randy Shilts. 1987. And the Band Played On: Politics, People and the AIDS Epidemic. New York: St. Martins Press.
Topic 5: Physicians
Eliot Freidson. 1975. Doctoring Together. New York: Elsevier
Paul Starr. 1984. The Social Transformation of American Medicine. New York: Basic Books.
Topic 6: Quality and Inequality
Robert G. Evans, M. L. Barer and T. R. Marmor eds. 1994. Why Are Some People Healthy, and Others Not? The Determinants of Health in Populations. New York: Aldine de Gruyter.
Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Institute of Medicine.
Ichiro Kawachi and Bruce P. Kennedy. 2002. The Health of Nations: Why Inequality Is Harmful to Your Health. New York: The New Press.
Topic 7: Miscellaneous
Thomas E. Mann and Norman Ornstein eds.. 1995. Intensive Care: How Congress Shapes Health Care Policy. Washington, D.C.: American Enterprise Institute and The Brookings Institution.
Thomas Rice. 2002. The Economics of Health Reconsidered 2nd ed. Chicago: Health Administration Press.
Rosemary Stevens. 1989. In Sickness and in Wealth. New York: Basic Books.