Doane College
Lincoln Campus
Bachelor of Science in Nursing Program
NRS 315 – Health Care Policy in the United States
Autumn Term 2012 (August 20 – October 20)
Bruce R. Rieker, J.D.
Vice President, Advocacy
Nebraska Hospital Association
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Doane College
Bachelor of Science in Nursing Program
Autumn Term 2012 (August 20 – October 20)
Lincoln Campus
Syllabus: NRS 315 – Health Care Policy in the United States (3 credits)
Adjunct Instructor
Bruce R. Rieker, J.D.
Vice President, Advocacy, Nebraska Hospital Association
3255 Salt Creek Circle, Suite 100, Lincoln, NE 68504
Direct phone: 402-742-8146
Cell phone: 402-432-4185
Email: brieker@nhanet.org
Class Dates and Hours
Class dates
 Eight scheduled classes occurring on the following Mondays: August 20, 27; September
10, 17, 24; and, October 1, 8 and 15.
 In observance of Labor Day, there will not be class on September 3.
Class hours
 Evenings: 6:00-10:30 p.m.
Office hours
 Immediately before and after class
 By appointment.
Course Description
This course examines the development of health policy in the United States and factors that
affect future health policy initiatives. The course will examine critical health care policy issues
facing the United States such as rising costs, quality of services, financing of the system, and
adoption of new technologies. Students will learn the basic elements underlying financing,
organization and delivery of health care services including Medicare, Medicaid, access to health
care and the relationship between the public and private sectors on health policy. Upon
completion of the course, students will understand how policy affects the development of health
care legislation, and the process of political compromise and real world limitations upon the
implementation of legislation.
Course Objectives
In these rapidly changing times, current and future health care policy at the federal and state
levels will have a significant impact on the accessibility, affordability, quality and utilization of
health care services in our state and across the country. This course is intended to help you gain
an understanding of the various factors that influence federal and state policy decisions about
health care, how they interact with each other, what contributes to their effectiveness, and what
causes them to be ineffective. In this course, we will pay significant attention to the
implementation of the Patient Protection and Affordable Care Act (PPACA) and its impact on
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health care cost growth, public programs such as Medicare and Medicaid, health insurance,
quality and the states with particular emphasis on Nebraska.
Specific learning objectives include:
 To develop a comprehensive understanding of how health care is currently delivered in
the United States, how federal health care reform will change that system.
 To be able to distinguish between effective and ineffective health care policies.
 To understand the influence of public policy on the organization, delivery and financing of
health care.
 To understand the social, political and economic forces that shape health policies.
 To develop skills that enable you to create responsible public policy that will improve the
efficiency and effectiveness of our nation’s health care delivery system.
 To enhance your ability to analyze an issue, including an examination of the rules and
regulations that apply, formulate appropriate and practical policy changes that will improve
the situation and articulate your recommendations coherently verbally and in writing.
Format
Classes will be a combination of lectures and discussions. The instructor will introduce subjects,
initiate discussions and guide those conversations. Subject matter for discussion and written
assignments will include health care reform, cost growth, Medicare, Medicaid, insurance, state
and federal responsibilities and quality. Students are expected to actively participate in the
discussion, including weekly submission of at least two discussion questions based on the
readings and current events. Discussion questions should be emailed to the instructor at least 24
hours prior to each class.
Protocol and Expectations
No experience in health care public policy is required. This class is meant to be interesting and
engaging. The topic is current and it affects every one of you. This course will give you the
opportunity to analyze critical components for improving the financing and delivery of high quality
health care in America.
We will start and finish on time. Because of the seminar nature of this class, attendance is
required. A missed class without prior approval will result in participation reduction of 5%. If you
must miss a class or if something has made it impossible for you to be adequately prepared, let
the instructor know before class. Distractions during class must be kept to a minimum. Cell
phones and pagers should be turned off or placed in a silent mode. Please do not use laptops or
other electronic devices in class except as tools that augment the classroom learning experience.
Students will gain the most from the class through participation in discussions and student
interaction. Every student is expected to participate and should be prepared to discuss the
required readings for each class. The instructor reserves the right to call on students specifically
to engage them, ask follow-up questions and to push them to think deeper.
Your class participation score will be based on your demonstration of your own learning and your
contribution to the learning of others. If the overall quality of the class discussion is high,
everyone will benefit and the participation score for you and the other students will reflect that.
Examples of active participation include, but are not limited to:
 Comments that reflect an understanding of the reading and lecture material.
 Effective connection of ideas.
 Asking questions when you do not understand or do not agree with something that you
read or heard in preparation for and during class.
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Encouraging others to participate.
Actively listening to others and trying to build on their ideas.
Sharing relevant experiences that pertain to the subject matter.
Academic Integrity
Academic integrity is essential to a positive teaching and learning environment. All students
enrolled in this course are expected to complete coursework responsibilities with fairness and
honesty. Scholastic dishonesty by seeking an unfair advantage over others or misrepresenting
someone else's work as your own can result in disciplinary action up to, and including, a failing
grade.
Grading
Students will be expected to complete the assigned readings, attend and participate in class
discussions and write three papers.
Grades for the course will be determined by the following:
1. Attendance: 10%
2. Reading analysis and class participation: 30%
3. First writing assignment: 20%
4. Second writing assignment: 20%
5. Third writing assignment: 20%
6. Final letter grades will be calculated by aggregating the scores for the five (5) criteria
above:
A = 93 - 100%
B = 85 - <93%
C = 77 - <85%
D = 70 - <77%
F = <70%
Required Reading Materials
 Links to readings available online are listed in syllabus.
 Readings not available online will be given out at the beginning of the course.
 Additional materials may be distributed during the course of the term.
Writing Assignments
Overview
Each class participant will complete three writing assignments. Each written work should not
exceed 1,500 words; however, in addition to the written text you are allowed an additional two
pages of exhibits with no more than two exhibits per page. Your papers should be written as if
you were employed by a state or federal policymaker who has assigned you this task. Your
performance evaluation will depend on you completing the assignment in a professional and
thoughtful matter. Form and substance are both important. Each assignment will be based on
subject matter covered in class.
In all written work, attention will be given to clarity, organization, depth of analysis and
conclusions. Some general guidelines for preparing an effective document include:
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Be concise and provide a strong logical foundation for your recommendations.
Provide well-organized, coherent analysis; including an examination of reasonable
options.
Provide recommendations that are cost-effective and appropriate.
Clearly label and explain figures, charts and graphs.
Explicitly state your purpose in the first paragraph or two.
Use title pages and page numbers.
All papers should be submitted to the instructor via email before 5:00 pm on the date they are
due. Late papers, without prior instructor approval, will not be accepted.
First Writing Assignment
At the conclusion of the third class about “Cost Growth” scheduled on 9/10/12, each class
participant will be given two weeks to prepare and submit a written document that examines
current policies and programs intended to control growth in health care costs, evaluating them for
their relative effectiveness and making recommendations as to how they can be improved or why
they should be discontinued. The first writing assignment is due on 9/24/12.
Second Writing Assignment
At the conclusion of the fifth class about “Medicaid” scheduled on 9/24/12, each class participant
will be given two weeks to prepare and submit a written document that examines how the state
and federal Medicaid programs could be improved with specific attention given to services
provided, eligibility, financing and utilization of services. The second writing assignment is due on
10/8/12.
Third Writing Assignment
At the conclusion of the seventh class about “State Responsibilities” scheduled on 10/8/12, each
class participant will be given two weeks to prepare and submit a written document that provides
a recommended framework for the design of a state-based insurance exchange with specific
attention given to what type of business model it should have, how it should be governed, and
how expansive or limited its role should be in promoting insurance competition, driving quality
improvement, providing cost and quality data on health plans, simplifying the purchase of
insurance and controlling costs. The third writing assignment is due on 10/22/12.
Class Schedule and Descriptions
8/20/12: Course Introduction and Analysis of the United States Health Care System
After reviewing the class format, expectations and grading of this course, the goal of the first
lecture and class discussion is to assess the structure, goals and performance of the U.S. health
system. Specific attention will be given to the progress made over the past 50 years as well as to
the challenges that existed leading up to the Patient Protection and Affordable Care Act (PPACA)
enacted into law in 2010, providing a foundation for discussion throughout the course designed to
critically evaluate the impact health care policy has had and will have on the country, individual
states, providers and consumers.
Required reading
 Atul Gawande, “The Cost Conundrum,” The New Yorker: June 1, 2009.
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http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande
John Holahan, Bow Garrett, Rising Unemployment, Medicaid and the Uninsured, KCMU,
January 2009.
http://www.kff.org/uninsured/upload/7850.pdf
David M. Cutler, “Health Care Modernization Will Reduce the Deficit” (Washington: Center
for American Progress Action Fund, May 2009).
http://www.americanprogressaction.org/issues/2009/05/health_modernization.html
Economists letter to President Obama on Health Reform.
http://economix.blogs.nytimes.com/2009/11/17/economists-letter-to-obama-on-healthcare-reform/
Cutler DM, Rosen AB, Vijan S. The value of medical spending in the United States,
1960-2000. N Engl J Med. 2006 Aug 31;355(9):920-7.
http://www.nejm.org/doi/pdf/10.1056/NEJMsa054744
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Centers for Medicare and Medicaid Services, Office of the Actuary, “National
Health Expenditures Projections 2009-2019” [Available at:
https://www.cms.gov/NationalHealthExpendData/downloads/proj2009.pdf]
8/27/12: PPACA
The main objective of this session is to examine key elements of the PPACA. Numerous
administrations have tackled health care reform; some better than others. Particular attention will
be given to why President Obama’s administration and Congress were able to make sweeping
changes to the nation’s health care system and what the key components will mean for
consumers, providers and taxpayers.
Required reading
 Summary of New Health Reform Law, Henry J. Kaiser Family Foundation Health Reform
Source.
http://www.kff.org/healthreform/upload/8061.pdf
 American Hospital Association. May 2010. Summary of the Most Significant Health
Reform Changes Affecting Hospitals and other Employers.
http://www.aha.org/aha/advisory/2010/100511-legislative-adv.pdf?group=hospital
 Drew Altman, “Implementation is Forever,” Pulling It Together, Kaiser Family Foundation,
April 5, 2010.
http://www.kff.org/pullingittogether/040610_altman.cfm
 Implementation Timeline, Henry J. Kaiser Foundation Health Reform Source.
http://healthreform.kff.org/timeline.aspx
 Kaiser Family Foundation. April 2010. Health Care Reform and the CLASS Act.
http://www.kff.org/healthreform/upload/8069.pdf.
9/10/12: Cost Growth
This session will provide an analysis of the factors that cause increases in health care spending
and the consequences of continued spending growth.
Required reading
 Kaiser. U.S. Health Care Costs. March 2010.
http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx
 American Hospital Association. Trendwatch: The Cost of Caring: Drivers of Spending on
Hospital Care
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http://www.aha.org/aha/trendwatch/2011/11mar-tw-costofcaring.pdf
 Buntin MB and Cutler D. “The Two Trillion Dollar Solution: Saving money by modernizing
the health care system.” The Center for American Progress 2009. Available at:
http://www.americanprogress.org/issues/2009/06/pdf/2trillion_solution.pdf
 Ginsburg PB. “High and rising health care costs: Demystifying U.S. health care spending.”
The Synthesis Project, The Robert Wood Johnson Foundation. Available at:
http://www.rwjf.org/files/research/101508.policysynthesis.costdrivers.rpt.pdf
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9/17/12: Medicare
This session will examine Medicare, its design and its challenges. Throughout its existence since
1965, Medicare has withstood challenges about its design, payment systems and stability. Fear
about its insolvency has been a cloud over the program for years. Medicare is central to the
PPACA as more than half of the $938 billion price tag will be paid from Medicare savings.
Required reading
 Kaiser Family Foundation, Medicare: A Primer. April, 2010.
http://www.kff.org/medicare/upload/7615-03.pdf
 Ball R.M. “What Medicare’s Architects Had in Mind.” Health Affairs 14(4), 1995: 62-72.
http://content.healthaffairs.org/cgi/reprint/14/4/62
 Robert Berenson, “Implementing Health Reform – Why Medicare Matters,” New England
Journal of Medicine, May 26, 2010.
http://healthpolicyandreform.nejm.org/?p=3480&query=TOC
 American Hospital Association, Medicare. 2011
http://www.aha.org/aha/content/2011/pdf/11-medicare.pdf
 National Health Policy Forum. The Basics – Medicare. January 2011
http://www.nhpf.org/library/the-basics/Basic_Medicare_01-24-11.pdf
 Henry J. Kaiser Family Foundation Health Reform Source. State Health Facts
http://www.statehealthfacts.org/comparecat.jsp?cat=6
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9/24/12: Medicaid
Medicaid is a “shared” state/federal program in existence since 1965; designed to primarily serve
as a safety net for low income women and children. The objective of this session will be to review
the history of the program; the role of states and the federal government in its design, operation
and funding; and, the new role it may play based on the June, 2012 U.S. Supreme Court ruling.
Required reading
 Kaiser Commission on Medicaid and the Uninsured, “Medicaid: A Primer,” June 2010.
http://www.kff.org/medicaid/upload/7334-04.pdf
 Kaiser Commission on Medicaid and the Uninsured,” Explaining Health Care Reform:
Questions about Medicaid’s Role,” April 2010.
http://www.kff.org/healthreform/upload/7920-02.pdf
 Kaiser Commission on Medicaid and the Uninsured, “Optimizing Medicaid Enrollment:
Perspectives on Strengthening Medicaid’s Reach under Health Care Reform,” April 2010.
http://www.kff.org/healthreform/upload/8068_ES.pdf
 Kaiser Commission on Medicaid and the Uninsured, “Medicaid Beneficiaries and Access
to Care,” April 2010.
http://www.kff.org/medicaid/upload/8000-02.pdf
 Douglas Holtz-Eakin and Michael Ramlet, “Healthcare Reform and Medicaid: Patient
Access, Emergency Department Use and Financial Implications for Hospitals and States,”
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(American Action Forum, September 2010).
http://www.politico.com/static/PPM170_100906_medicaid.html
Kaiser Family Foundation, Focus on Health Reform, “Medicaid and Children’s Health
Insurance Provisions in the New Health Reform Law” (April 2010)
http://www.kff.org/healthreform/upload/7952-03.pdf
John Iglehart, “Medicaid at a Crossroads, New England Journal of Medicine, April 6, 2011.
http://healthpolicyandreform.nejm.org/?p=14124&query=TOC
Austin Frakt, Ph.D., Aaron E. Carroll, M.D., Harold A. Pollack, Ph.D., and Uwe Reinhardt,
Ph.D., “Our Flawed but Beneficial Medicaid Program,” New England Journal of Medicine,
April 6, 2011.
http://healthpolicyandreform.nejm.org/?p=14122&query=TOC
Rosenbaum, S. “A ‘Customary and Necessary’ Program – Medicaid and Health Care
Reform,” NEJM 362(21), 2010: 1952-1955.
http://www.nejm.org/doi/full/10.1056/NEJMp1003890
Edwin Park and Matt Broaddus, “Medicaid Block Grant would Shift Financial Risks and
Costs to the States,” Center on Budget and Policy Priorities, February 23, 2011.
http://www.cbpp.org/files/2-23-11health.pdf
10/1/12: Health Insurance
The objective of this session will be to examine the underlying principles of health insurance, the
structure of the private insurance market, and an overview of the key insurance elements of the
PPACA.
Required reading
 Claxton, Gary, “How Private Health Care Coverage Works: A Primer,” A Henry J. Kaiser
Family Foundation Report, April 2008.
http://www.kff.org/insurance/upload/7766.pdf
 Nixon Peabody. Health care reform: a primer for employers. April 2010.
http://www.nixonpeabody.com/publications_detail3.asp?ID=3233
 Mercer. Chart: Key employer health care reform elements. March 2010.
http://www.uschamber.com/sites/default/files/chambers/files/healthcarelawchartkeyemploy
erchangesmercer.pdf
 American Progress. Implications of Health Care Reform for Employers: An Analysis of the
Patient Protection and Affordable Care Act. Kosali Simon. May 2010.
http://www.americanprogress.org/issues/2010/05/pdf/health_employers.pdf
 Employee Benefits Research Institute. Employer and Employee Reactions to Health
Reform: Findings from the 2010 EBRI/MGA Consumer Engagement in Health Care
Survey and the 2010 SHRM. Organizations’ Response to Health Care Reform Poll
http://www.ebri.org/pdf/notespdf/EBRI.Notes.Jan-11.FinalFlow.pdf
 Questions and Answers: Keeping the Health Plan You Have: The Affordable Care Act and
“Grandfathered” Health Plans
http://www.healthreform.gov/about/grandfathering.html
 How Brokers Can Find Opportunities in the Health Care Reform Era. Health Care Reform
Magazine. May 2011.
http://www.healthcarereformmagazine.com/article/how-brokers-can-find-opportunities-inthe-health-care-reform-era.html
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10/8/12: State Responsibilities
States have always played a crucial role in delivering and financing health services, particularly to
low income populations and that role will increase as a result of the PPACA. The legislated
changes come at a time of tremendous fiscal pressure for the states and some have indicated
their strong opposition. In this session we will examine the magnitude of the tasks to be
accomplished and the challenges to be faced by the states in implementing health reform.
Required reading
 Financing New Medicaid Coverage under Health Reform: The Role of the Federal
Government and States (May 2010).
http://www.kff.org/healthreform/upload/8072.pdf
 A. and R. Scheppach. “New Roles for States in Health Reform Implementation,” Health
Affairs 29(6), 2010: 1178-1182.
http://www.hsd.state.nm.us/pdf/hcr/Role%20of%20States%20in%20HC%20Reform%20(2
).pdf
 Henry J. Kaiser Family Foundation. Medicaid Coverage and Spending in Health Reform:
National and State-by-State Results for Adults at or Below 133% FPL. May 2010.
http://www.kff.org/healthreform/upload/Medicaid-Coverage-and-Spending-in-HealthReform-National-and-State-By-State-Results-for-Adults-at-or-Below-133-FPL.pdf
 Milliman. Patient Protection and Affordable Care Act with House Reconciliation – Financial
Analysis. May 2010.
http://www.governor.nebraska.gov/news/2010/08/pdf/Nebraska%20Medicaid%20PPACA
%20Fiscal%20Impact.pdf
 T. S. Jost, “Health Insurance Exchanges and the Affordable Care Act: Key Policy Issues,”
The Commonwealth Fund, July 2010.
http://www.commonwealthfund.org/Content/Publications/Fund-Reports/2010/Jul/HealthInsurance-Exchanges-and-the-Affordable-Care-Act.aspx
 “Implementing Health Reform: Federal Rules and State Roles” (Alliance for Health
Reform, October 2010).
http://www.allhealth.org/publications/State_health_issues/Implementing_Health_Reform__Federal_Rules_and_State_Roles_100.pdf
 HHS Report, “States and the Affordable Care Act: More Funding, More Flexibility,”
February 25, 2011.
http://www.healthcare.gov/center/reports/states02252011a.pdf
 National Conference of State Legislatures. The 2011 State Legislators’ Check List for
Health Reform Implementation. February 2011. Rachel Morgan.
http://www.ncsl.org/documents/health/State_Legislators_Checkdec20.pdf
10/15/12: Quality
This session will provide an introduction to the current state of quality of care in the U.S and
efforts to improve it; focusing on two recent prominent approaches – public reporting and pay for
performance. We will explore the details and conceptual underpinnings of these approaches, their
strengths and limitations, and quality provisions included in the PPACA.
Required reading
 Agency for Healthcare Research and Quality. Improving Health Care Quality. Fact Sheet.
September 2002.
http://www.ahrq.gov/news/qualfact.pdf
 McDermott, Will and Emery. Health Care Reform: Quality Initiatives – the Thread That
Ties It All Together. May 2010.
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http://www.mwe.com/index.cfm/fuseaction/publications.nldetail/object_id/21970108-acee48b5-b82f-dda8cad89656.cfm
Foley and Lardner, LLP. PPACA Will Drive Quality Health Care Reform. May 2010.
http://www.foley.com/publications/pub_detail.aspx?pubid=7141
American Hospital Association. Improving Hospital Performance. 2011.
http://www.aha.org/aha/content/2011/pdf/11-hospi-performance.pdf
Institute of Medicine (2009). Washington, D.C. Initial national priorities for comparative
effectiveness research. Report Brief.
http://www.iom.edu/Reports/2009/ComparativeEffectivenessResearchPriorities.aspx
Congressional Budget Office, Research on the Comparative Effectiveness of Medical
Treatments, December 2007.
http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf
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