New York University
Robert F. Wagner Graduate School of Public Service
HPAM-GP.2836 – Current Issues in Health Policy
Spring, 2015 - Version 1.1
Professor John Billings
Tuesdays – 4:55-6:35
Location: GCASL (238 Thompson Street) – Room 269
Course Description
This course is an introduction to major health policy issues and examines the role of government
in the health care system. An important focus of the course is an assessment of the role of policy
analysis in the formation and implementation of national and local health policy. Because much
of government health policy relates to or is implemented through payment systems, several
sessions involve some discussion of the policy implications of how government pays for care,
with a more detailed review of the economics of payment systems available in Health Economics
and Payment Systems (P11.1832). The role of the legal system with respect to adverse medical
outcomes, economic rights, and individual rights is also discussed. Proposals for health policy
reform at the national and local level are examined throughout the course, as well as Medicare
and Medicaid reforms currently being implemented or considered.
Course Requirements/Grading
There are three assignments are required for the course: two papers (one ≤ 8 pages and one ≤ 6
pages) and a PowerPoint slide assignment bases on the first paper. These assignments account
for 85% of the final grade (35% paper 1, 25% PowerPoint assignment, and 25% paper 2). Class
discussion and debate are integral to the course and will account for 15% of the final grade.
Papers can be submitted in class or NYU Classes File Exchange. There is no midterm or final
exam.
Students are expected to have studied the assigned readings. The readings for the course are
primarily journal articles that will be posted in the Resources/Assigned Readings section of NYU
Classes. There is no text book for the course, and the books required for the second paper are
readily available at area bookstores or on the web (e.g., amazon.com, barnesandnoble.com, etc.).
Copies of PowerPoint materials used in class will be posted in the Resources/Session Notes
section on the NYU Classes site at least 24 hours in advance of the class.
If you have questions about the reading materials or you need other help, please contact my
administrative assistant, Christopher Harris [295 Lafayette Street - 3rd Floor - 212-998-7416 –
christopher.harris@nyu.edu].
Office Hours
By appointment (212-998-7455) - john.billings@nyu.edu
295 Lafayette Street - 3010
HPAM-GP.2836
Current Issues in Health Policy
Session 1 – 1/27/15: Snow day – no class
Session 2 – 2/03/15: Square One: The role of government in health/health care

Description of course content, goals, and requirements

A discussion of the role of policy analysis in public policy formation and the
impact of public policy on the health system

Objectives of government in health and health care, discussion of limitations
of government, and some examples

Discussion of implications for policy
Required reading:
S. Schoenbaum S, A. Audet, and K. Davis, “Obtaining Greater Value from Health Care:
The Roles of the U.S. Government,” Health Affairs (November/December 2003): 183190.
N. Tang, J. Eisenberg, G Meyer, “The Roles of Government in Improving Health Care
Quality and Safety,” Joint Commission Journal on Quality and Safety (January, 2004):
47-54.
Session 3 – 2/10/15: Square 2: How health care is organized/financed/paid for

Brief overview of how health care is organized, financed, and paid for

A little bit about insurance and “managed” care

Discussion of the implications for policy
Required reading:
Kaiser Family Foundation: How Private Health Coverage Works: A Primer – 2008
Update. http://www.kff.org/insurance/7766.cfm
Get a little health economics by reviewing this:
S. Glied, “Health Insurance and Market Failure since Arrow”, Columbia University,
Project Muse.
Suggested reading on how the health care delivery system is organized:
T. Bodenheimer and K. Grumbach, Understanding Health Policy – Fifth Edition (New
York: McGraw Hill, 2008) – Chapters 4-7.
- or L.Shi, D. Singh, Delivering Health Care in America (Jones & Bartlett Publishers, 2003) –
Chapters 1, 7, 8, and 9 – Preview available at http://books.google.com
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A Kovner, J Knickman, Health Care Delivery in the United States – 10th Edition (New
York: Springer Publishing Company, 2011) – Chapters 4-5.
Session 3 (4) – 2/17/15: Square 3: Medical practice and health policy

Review of the enormous variation in medical practice

Discussion of causes of variation

Discussion of the implications for policy
Required reading:
E. Fisher, D. Wennberg, T. Stukel, et al., “The Implications of Regional Variation in
Medicare Spending - Part 2: Health Outcomes and Satisfaction with Care,” Annals of
Internal Medicine 138, No. 4 (2003): 288-299
J. Wennberg, E. Fisher, T. Stukel, et al., “Use of Hospitals, Physician Visits, and Hospice
During the Last Six Months of Life among Cohorts Loyal to Highly Respected Hospitals
in the United States,” British Medical Journal 328, No. 7440 (March 13, 2004): 607-610.
K. Kozhimannil, M. Law, and B. Virnig, “Cesarean Delivery Rates Vary Tenfold Among
US Hospitals; Reducing Variation May Address Quality and Cost Issues,” Health Affairs
(March, 2013): 527-535
D. Eddy, “Evidence-Based Medicine: A Unified Approach,” Health Affairs
(January/February, 2005): 9-17.
D. Jones, “Visions of a Cure,” Isis (September 2000):91:504-541 –
[http://www.jstor.org/browse/00211753/ap010310?frame=noframe&userID=807af334@
nyu.edu/01cc99333c3c2f10d557f64a8&dpi=3&config=jstor]
A. Gawande, “The Cost Conundrum,” New Yorker, June 1, 2009
Sessions 5-6 – 2/24/15 and 3/03/15: Medicare: The basics and Issues for reform

A discussion of the role and objectives of government in health

Description of who and what is covered by Medicare

Review of how Medicare pays for health care

Description of the recent expansion Medicare to provide coverage for
prescription drugs
Required reading:
C. Eibner, D. Goldman, J. Sullivan et al., “Three Large-Scale Changes to the Medicare
Program Could Curb Its Costs but Also Reduce Enrollment,” Health Affairs (May, 2013):
891-899.
K. Davis, C. Shoen, S. Guterman, “Medicare Essential: An Option to Promote Better
Care and Curb Spending Growth,” Health Affairs (May, 2013)” 900-909.
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Henry J. Kaiser Family Foundation, Prescription Drug Coverage for Medicare
Beneficiaries: A Summary of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (December 10, 2003),
http://www.kff.org/medicare/loader.cfm?url=/commonspot/security/getfile.cfm&PageID=28710
Also take a look at:
Henry J. Kaiser Family Foundation, Policy Options to Sustain Medicare for the Future,
http://kaiserfamilyfoundation.files.wordpress.com/2013/02/8402.pdf
Medicare and You: 2015 - http://www.medicare.gov/Pubs/pdf/10050.pdf
Sessions 6-7 – 3/03/15 and 3/10/15: Medicaid: The basics and issues for reform

History and financing of Medicaid

Description of who and what is covered by Medicaid

Discussion of recent reforms/Issues for reform/Role of managed care
Required reading:
S. Decker, “In 2011 Nearly One-Third of Physicians Said They Would Not Accept New
Medicaid Patients but Rising Fees May Help,” Health Affairs (August, 2012) 1673-1679.
B. Sommers, K. Baicker, and A. Epstein, Mortality and Access to Care among Adults
after State Medicaid Expansions,” NEJM 2012;367:1025-34.
D. Draper, R. Hurley, and A. Short, “Medicaid Managed Care: The Last Bastion of the
HMO?” Health Affairs (March/April 2004): 155-167.
J. Billings, T. Mijanovich, “Improving the Management of Care for High-Cost Medicaid
Patients” Health Affairs no 6 (2007) 1643-1655.
See also: Medicaid: A Primer 2013 - http://kff.org/medicaid/issue-brief/medicaid-aprimer/
Session 8 – 3/24/15: The major challenges confronting the health “system”:
Part 1 - Disparities and Part 2 - Uninsurance

Overview of disparities in health services, utilization, and outcomes

Discussion of the factors that are contributing to these disparities

Description of the size and characteristics of the uninsured population

Review of the causes of uninsurance
Required Reading:
J. Billings, L. Zeitel, J. Lukomnik, et al., “Impact of Socioeconomic Status on Hospital
Use in New York City” Health Affairs (Spring 1993): 162-173.
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J. Billings, J. Anderson, L. Newman, “Recent Findings on Preventable Hospitalizations”
Health Affairs (Fall 1996): 239-249.
J. Billings, “Management Matters: Strengthening the Research Base to Help Improve
Performance of Safety Net Providers,” Health Care Management Review 28, No 4 2003):
323-334.
Jha AK, Orav EJ. Low-Quality, High-Cost Hospitals, Mainly in the South, Care for
Sharply Higher Shares of Elderly Black, Hispanic, and Medicaid Patients, Health Affairs
(October 2011): 1904-1911.
J Holahan, A Cook, “The U.S. Health Economy and Changes in Health Insurance
Coverage,” Health Affairs – Web Exclusive (20 February 2008) W135-144
Kaiser Family Foundation, The Uninsured: A Primer, December, 2014 http://kff.org/uninsured/report/the-uninsured-a-primer/
Session 9 – 3/31/15: The major challenges confronting the health “system”:
Part 3 - Costs

Description of the dynamics of current cost increases

Review of the causes and implications of cost increase

Discussion of the implications of these challenges for policy makers and
providers and for the current health reform initiative
Required Reading:
D. Altman and L. Levitt, “The Sad History of Health Care Cost Containment as Told in
One Chart,” Health Affairs – Web Exclusive (23 January 2002): W83-4.
Phillipson T, Eber M, Lakdawalla DN, “An Analysis of Whether Higher Health Care
Spending in the United States Versus Europe is “Worth It” in the Case of Cancer,” Health
Affairs (April, 2012): 667-675.
P. Cunningham, “The Growing Financial Burden of Health Care,” Health Affairs (May
2010): 1037-1044.
W Hsiao, A Knight, S Kappel, et al., “What Other States Can Learn from Vermont’s
Bold Experiment: Embracing A Single-Payer Health Care Financing System,” Health
Affairs (July 2011): 1232-1241.
U. E. Reinhardt, Is it Time for a More Rational All-Payer System? Health Affairs
(November, 2011): 2125-2133.
D. Cutler and N. Sahni, “If Slow Rate of Health Care Spending Growth Persists,
Projections May Be Off by $700 Billion,” Health Affairs (May, 2013): 841-850.
Song Z, Safran DG, Landon BD et al., “The ‘Alternative Quality Contract,’ Based on a
Global Budget, Lowered Medical Spending and Improved Quality” Health Affairs
(August, 2012): 1885-1894.
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Session 10 – 4/07/15: Prior efforts to respond to these challenges: The role
of the states, the Clinton Health Plan, and other federal
initiatives

Overview of policies/programs at the federal, state, and local level to reduce
disparities, expand coverage, and control costs

Discussion of the strengths and limits of state/local initiatives

Discussion of the Clinton health plan, what problems it might have solved or
created, and why it failed

Implications for current reform initiatives
Required Reading:
J. Holahan, L. Blumberg, A. Weil, et al, “Roadmap to Coverage – Report for the Blue
Cross Blue Shield of Massachusetts Foundation,” October, 2005
S. Long and K Stockey, “Sustaining Health Reform in a Recession: An Update on
Massachusetts,” Health Affairs (June 2010): 1234-1241.
W. Zelman, “The Rationale behind the Clinton Health Care Reform Plan,” Health Affairs
(Spring 1994): 9-29.
D. Yankelovich, “The Debate That Wasn’t: The Public and the Clinton Health Plan,”
Health Affairs (Spring 1995): 7-23.
R. Blendon, M. Brodie, and J. Benson, “What Happened to America’s Support for the
Clinton Health Plan,” Health Affairs (Summer 1995): 7-23.
Session 11 – 4/14/15: Health Reform 2010

Overview of Patient Protection and Affordable Care Act (PPACA)

Discussion policy, politics, and power
Required Reading:
Kaiser Family Foundation: “Summary of New Health Reform Law” –
http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf
Kaiser Family Foundation: “Health Reform Implementation Timeline” –
http://kff.org/interactive/implementation-timeline/
J Morone, “Presidents and Health Reform: From Franklin D. Roosevelt to Barack
Obama,” Health Affairs (June 2010): 1096-1100.
J Oberlander, “Long Time Coming: Why Health Reform Finally Passed,” Health Affairs
(June 2010): 1112-1116.
S. Shortell, L Casalino, and E. Fisher, “How CMS Innovation Should Test Accountable
Care Organizations,” Health Affairs (July 2010): 1293-1298.
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C. Price and C. Eibner, “For States That Opt Out of Medicaid Expansion: 3.6 Million
Fewer Insured and $8.4 Billion Less in Federal Payments,” Health Affairs (June, 2013):
1030-1036.
Session 12 – 4/21/15: More policy issues concerning the pharmaceutical
industry

Overview of the major policy issues concerning the pharmaceutical industry

Discussion of the factors that are contributing to these emergence of these
issues now

Discussion of the role of government with respect to the pharmaceutical
industry
Required Reading:
P. Stein and E Valery, “Competition: An Antidote to the High Price of Prescription
Drugs,” Health Affairs (July/August 2004): 151-158.
K. Kaphingst and W. DeJong, “The Educational Potential of Direct-to-Consumer
Prescription Drug Advertising,” Health Affairs (July/August 2004): 143-150.
J. Jeffords, “Direct-to-Consumer Drug Advertising: You Get What You Pay For,”
Health Affairs - Web Exclusive (28 April 2004): W4 253-255.
P. Kelly, “DTC Advertising’s Benefits Far Outweigh Its Imperfections,” Health Affairs Web Exclusive (28 April 2004): W4 246-248.
C. Manz, J. Ross, and D. Grande, “Marketing to Physicians in a Digital World,” NEJM
(November 14, 2014) 371;20: 1857-59/
Optional reading:
J. Weisman, D. Blumenthal, A Silk, et al., “Consumers’ Reports on the Health Effects of
Direct-to-Consumer Drug Advertising,” Health Affairs - Web Exclusive (26 February
2003): W3 82-95.
J. Weisman, D. Blumenthal, A Silk, et al., “Physicians Report on Patient Encounters
Involving Direct-to-Consumer Drug Advertising,” Health Affairs - Web Exclusive (28
April 2004): W4 219-233.
Session 13 – 4/28/15: Medical errors – Medical malpractice

Brief overview of current malpractice law

Description of what is known about medical errors

Analysis of the effectiveness of the legal system and malpractice law in
assuring quality and compensating victims of harm

Discussion of current “crisis” and proposals for reform
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Required reading:
Institute of Medicine, “Report Brief - To Err is Human: Building a Safer Health
System” - http://www.nap.edu/catalog/9728.html
M. Hatlie and S. Sheridan, “The Medical Liability Crisis of 2003: Must We Squander the
Chance to Put Patients First?” Health Affairs (July/August 2003): 37-40.
C. Landrigan, G. Parry, C. Bones et al., “Temporal Trends in Rates of Patient Harm
Resulting from Medical Care,” NEJM 2010;363:2124-34.
D. Waxman, M. Greenberg, M. Ridgely, et al., “The Effect of Malpractice Reform on
Emergency Department Care,” NEJM (October 16, 2014) 371;16: 1518-1525
A.J. Starmer, N.D Spector, R. Srivastave, et al., “Change in Medical Errors after
Implementation of a Handoff Program,” NEJM (November 6, 2014) 371;19: 1803-12.
Session 14 – 5/05/15: Role of Patients – Making informed decisions

Patient’s rights to refuse/withdraw treatment

What information do patients need to make health care decisions (choice of
treatment, doctor/hospital, health plan, etc.)

What’s the best way to get information to patients
Required reading:
Cruzan v. Director, Missouri Department of Health – 497 U.S. 261 (1990)
http://caselaw.lp.findlaw.com/scripts/getcase.pl?court=us&vol=497&invol=261
M. Morgan, R Deber, H. Llewellyn-Thomas, “Randomized Controlled Trial of an
Interactive Videodisc Decision Aid for Patients with Ischemic Heart Disease,” Journal of
General Internal Medicine 15 No. 10 (2000): 685-693
A. O’Connor, H. Llewellyn-Thomas, and A. Flood, “Modifying Unwarranted Variations
in Health Care: Shared Decision Making Using Patient Decision Aids,” Health Affairs –
Web Exclusive (7 October 2004): VAR 63-72.
D. Arterburn, R Wellman, E Westbrook, et al., “Introducing Decision Aids at Group
Health Was Linked to Sharply Lower Hip and Knee Surgery Rates and Costs,” Health
Affairs (September, 2012): 2094-2104.
D. Veroff, A. Marr, and D. Wennberg, “Enhanced Support for Shared Decision Making
Reduced Costs of Care for Patients with Preference Sensitive Conditions,” Health Affairs
(February, 2013): 285-293.
E.O. Lee, E.J. Emanuel, “Shared Decision Making to Improve Care and Reduce Costs,”
NEJM (January 3, 2013) 368;1: 6-8.
New York State Department of Health, Acute Cardiac Surgery in New York State: 20092011 (March, 2014):
http://www.health.ny.gov/statistics/diseases/cardiovascular/heart_disease/docs/20092011_adult_cardiac_surgery.pdf
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REQUIRED ASSIGNEMNTS/PAPERS
Assignment 1 – Personal Resume (Pass/Fail) – Provide a very brief resume/vita/something
that describes who you are, employment experience (if any), and career goals (if any) and attach
a recent photo of yourself (try Xeroxing you ID if you can’t do any better).
Due Date: Session 2 – 2/03/15 – 11:59pm (submit in class or use NYU Classes File
Exchange)
Note: For papers 1 and 2 and assignment 2, you may work in teams of up to 3 students,
although working on team is not required. Teams must have members from at least two different
programs at Wagner or NYU and two different “professions”. Player trades are allowed, and
you can work on different teams for papers 1 and 2 (or no team on one or the other). For
assignment 2, you may submit as your paper 1 team, or you may submit individually. Submit
only one paper/assignment per team and list all the team members.
Paper 1 – The Dartmouth Atlas Memo (35% of final grade) - ≤ 8 pages – Take a look at the
website for the Dartmouth Atlas of Healthcare. There is an interactive site, where you can pick
out specific utilization measures for specific geographic areas or individual hospitals
(http://www.dartmouthatlas.org/), and there is also an area of the site where you can download
Excel or pdf files with the data (http://www.dartmouthatlas.org/downloads.aspx) – this latter site
much easier to navigate and I strongly recommend using it. Pick an example of variation in
utilization that you believe is unwarranted and describe the range of factors that are likely to
contribute to the differences among areas (or hospitals). Examples utilization rates on the site
include:
 Care of chronically ill patients during the last two years of life
(http://www.dartmouthatlas.org/tools/downloads.aspx?tab=40)
 Selected surgical discharge rates
(http://www.dartmouthatlas.org/tools/downloads.aspx?tab=41)
 Selected medical discharge rates
(http://www.dartmouthatlas.org/tools/downloads.aspx?tab=41)
 Children's health care in Northern New England, 2007-10
(http://www.dartmouthatlas.org/tools/downloads.aspx?tab=35)
 Prescription drug use, 2010
(http://www.dartmouthatlas.org/tools/downloads.aspx?tab=35)
Please look at utilization levels, not variation in mortality, costs/spending/reimbursement or
resource inputs that are reported in some files or tables. While you can write about some of the
“quality” measures (primary care access and quality or post discharge events) if you have an
abiding interest in these topics, I would much prefer you to focus on variation in rates of
utilization – also please note that these “quality” measures will be more difficult to tie into the
discussions we had in class.
After discussing the range of factors that affect variation in rates, pick one contributing factor
that you think is important (or that you think something can be done about it) and make some
suggestions about what might be done to reduce variation. Be specific and detailed in your
suggestions, including who ought to do what to whom. Be realistic, don’t make suggestions that
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cannot be implemented because of technical, financial, or political considerations. This is a
conceptual piece and not a research paper, but footnote sources of ideas from others that you use
for the causes of variation (or the suggested solutions if the ideas come from a specific source).
Please see more detailed instructions/suggestions in the PowerPoint presentation located in the
Other Material tab of NYU Classes.
Due Date: 3/03/15 – 11:59pm (submit in class or use NYU Classes File Exchange)
Assignment 2 – Dartmouth Atlas PowerPoint Slides (25% of final grade) – Take your
Dartmouth Atlas paper and make it into a PowerPoint presentation. As with the paper, describe
the “unwarranted” variation, discuss the potential causes of the variation, and make
recommendations on what might be done about it. Incorporate or address any suggestions that I
made in grading the paper. While substantive content matters, you will also be graded on how
clearly and effectively the material is presented. Don’t make slides too busy or have too much
text on a slide, and avoid cute graphics. You will not actually have to present the slides, but keep
the length to a presentation that would take not more than 15 minutes. If you worked on team on
the paper, you may submit as a team or individually.
Due Date: 4/07/15 – 11:59pm (submit in class or via NYU Classes File Exchnage)
Paper 2 – Book Memo (25% of final grade) - ≤ 6 pages – You are a newly hired policy staff
person for some senator, the governor of any state, a state legislator, a state/cityhealth
commissioner, the president of the National Association of Community Health Centers, CEO of
a large health insurance plan/managed care plan, a hospital CEO, or some other health
organization of your choice (domestic or international). Your boss walks by your cubicle and
plops down one of the books listed below and asks you to read it and tell her/him i) what it’s
about, ii) why it’s important, and iii) what ought to be done about it by your organization or boss.
Select a book from the list below and write a brief memo (remembering your boss has a very
short attention span and will stop reading if it goes beyond 6 pages). Make sure you identify
your hypothetical employer. If there is a book relevant to the class that you are dying to read that
is not on the list, let me know and, if I have read it or am willing to read it, the book can be
added to the list.

Adrian Nicole LeBlanc – Random Family: Love, Drugs, Trouble, and Coming of Age in
the Bronx.

Anne Fadiman – The Sprit Catches You and You Fall Down.

Sherwin Nulin – How We Die.

Eric Klineberg – Heat Wave: A Social Autopsy of Disaster in Chicago; Going Solo: The
Extraordinary Rise and Surprising Appeal of Living Alone

Laurie Kaye Abraham – Mama Might Be Better Off Dead: The Failure of Health Care in
Urban America.

Jerry Avorn – Powerful Medicines : The Benefits, Risks, and Costs of Prescription Drugs.

Andrew Solomon – The Noonday Demon.

Richard Deyo and Donald Patrick – Hope or Hype: The Obsession with Medical
Advances and the High Cost of False Promises.
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
Shannon Brownlee - Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer

Jerome Groopman – How Doctors Think

John Abramson - Overdosed America : The Broken Promise of American Medicine

Atul Gawande – Being Mortal: Medicine and What Matters in the End or The Checklist
Manifesto: How to Get Things Right.

David Kessler – The End of Overeating: Taking Control of the Insatiable American Appetite

John Wennberg – Tracking Medicine

Otis Brawley – How We Do Harm: A Doctor Breaks Ranks

Eric Manheimer - Twelve Patients: Life and Death at Bellevue Hospital

Angela Coulter – Engaging Patients in Healthcare

Nina Teicholz – The Big Fat Surprise

Elizabeth Bradley/Lauren Taylor – The American Health Care Paradox: Why Spending More
Is Getting Us Less

Sanjeep Jauhar – Doctored: The Disillusionment of an American Physician
Due Date: 5/05/15 – 11:59pm (submit in class or via NYU Classes File Exchnage)
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