Health Systems and Public Policy (MBAMGT 681)
Spring 2015
Wednesdays 5:30 p.m. to 8:15 p.m.
Instructor:
Louise E. Parker, Professor of Practice in Healthcare Management
Department of Management and Marketing
College of Management, UMASS Boston
Office Hours: Tuesdays, 3:00 p.m. to 5:00 p.m., Wednesdays from 3:00 to 4:00, or by appointment
Office: McCormack 5th Floor, Room 423
Email (preferred method of communication): Louise.Parker@umb.edu
Cell phone: (626) 497-9251
Course Description:
The healthcare industry is vast, highly complex, and dynamic affecting everyone throughout their
entire lives. This course explores the structure of healthcare systems including financing, services,
utilization, and access. It also examines the policies and the political pressures that shape those systems
over time. The first part of the course will focus on the US healthcare system, a complicated mixture of
for-profit, private not-for-profit, and governmental entities that comprises a large proportion of the US
economy relative to other high income nations. The course will examine why this complex and
relatively expensive system often fairs poorly compared to other high income nations in terms of
healthcare access and outcomes. It will also examine potential effects of the 2010 Patient Protection
and Affordable Care Act (PPACA). The second part of the course will focus on comparing the US
system with that of selected high and low to middle income nations.
This course is appropriate for management students interested in the health care industry, as well as,
public policy, nursing, and psychology students interested in healthcare policy, systems, and
management.
Course Policies:
Participation. Active learning is far more effective than passive learning. Therefore, class attendance
and active participation in class discussions are an essential and required part of this class. Students are
expected to provide thoughtful comments throughout class especially during the discussion periods.
Students are expected to read each week’s reading and complete any writing assignments prior to class.
Attendance. Students are expected to attend all classes. If this is not possible due to illness or a family
emergency, they need to contact Professor Parker and write a summary of that week’s reading in lieu
of participating in that week’s discussion.
Individual Work. The work on individual assignments is expected to be completed by the student
alone. While students may consult with each other and the professor, the work should be substantially
theirs. Students should cite any written material that influences their ideas including assigned readings.
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Spring 2015, Professor Parker
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Group Work. Most work environments require team work. Accordingly, this course has a team
assignment. Team members are expected to participate actively in each group effort and be able and
willing to discuss any portion of the work when asked.
Late Work. Students will receive a reduced grade should they hand in late work without prior
approval.
Grading:
• 15% Class Attendance and Discussion Participation: Pass/Fail Grading.
• 15% Weekly One Page American Health Care System Writing Assignments: Pass/Fail
Grading. Please submit via email prior to class, as well as, bring a paper copy with you to class.
• 30% Take Home Open Book Essay Exam: Letter Grade. Submit via email.
• 10% Team Comparative Health Care Systems in Class Presentations: Pass/Fail Grading.
Submit via email prior to class and presented in class.
• 30% Term Paper: Letter Grade submit via email.
Note: Submit all written assignments via email in Microsoft Word and all presentations via email in
PowerPoint.
Accommodations
The University of Massachusetts Boston is committed to providing reasonable academic
accommodations for all students with disabilities. This syllabus is available in alternate format upon
request. If you have a disability and feel you will need accommodations in this course, please contact
the Ross Center for Disability Services, Campus Center, Upper Level, Room 211 at 617.287.7430.
http://www.umb.edu/academics/vpass/disability/ After registration with the Ross Center, a student
should present and discuss the accommodations with the professor. Although a student can request
accommodations at any time, we recommend that students inform the professor of the need for
accommodations by the end of the Drop/Add period to ensure that accommodations are available for
the entirety of the course.
Code of Conduct and Academic Integrity
It is the expressed policy of the University that every aspect of academic life--not only formal
coursework situations, but all relationships and interactions connected to the educational process--shall
be conducted in an absolutely and uncompromisingly honest manner. The University presupposes that
any submission of work for academic credit is the student’s own and is in compliance with University
policies, including its policies on appropriate citation and plagiarism. These policies are spelled out in
the Code of Student Conduct. Students are required to adhere to the Code of Student Conduct,
including requirements for academic honesty, as delineated in the University of Massachusetts Boston
Graduate Catalogue and relevant program student handbook(s). UMB Code of Student Conduct
You are encouraged to visit and review the UMass website on Correct Citation and Avoiding
Plagiarism: http://umb.libguides.com/citations
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Readings and Assignments
Texts:
Almgren, G. (2013). Health Care politics, policy, and services: A social justice analysis (Second
Edition). New York: Springer Publishing
Johnson, J.A,, & Stoskopf, C.H. (2009). Comparative Health Systems: A Global Perspective. Boston:
Jones and Bartlett Publishers
Introduction
Week 1 (January 28th)
• Readings:
- Almgren, Chapter 1, A Primer on Theories of Social Justice and Defining the
Problem of Health Care
- Johnson & Stoskopf, Chapter 1, Introduction To Health Systems
• In Class Video, Frontline: Sick Around America
- If you would like to view this video again, you can find it online at:
http://www.pbs.org/wgbh/pages/frontline/sickaroundamerica/view/
The American Health Care System
Week 2 (February 4th): Historical Evolution of the U.S. Health Care System
Readings:
- Almgren, Chapter 2, The Historical Evolvement of the U.S. Health Care System
- Johnson & Stoskopf, Chapter 21, The Changing US Health Healthy System
• Consider the following questions while reading the text. We will discuss these in class.
Additionally, pick one of these questions and write an approximately one page answer.
According to sociologist Paul Starr (1982) the rise of medical professional sovereignty
enabled the American Medical Association to shape the US care system into one that
aligned with the medical profession’s economic interests rather than those of society
generally. In the 19th century, physicians were a weak profession of minor economic
significance that was bitterly divided and financially insecure. In the 20th century they
became a united and prosperous group by moving medical care from the home into the
marketplace and converting it into a commodity. Physicians exploited the progressive
belief in science over the populist support of self-reliance, to gain the cultural authority for
the medical profession. Having increased demand, they then controlled supply by ending
sectarian quarrels within medicine, restricting entry to the profession through licensing
laws and limited admissions to recently reformed medical schools, and establishing their
authority over medication.
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a. With the rise of corporate control over health care (e.g., private for-profit insurance
companies, for-profit hospitals), do you think the position of physicians has changed
compared to what it was in early to mid-twentieth century? Why or why not?
b. Many US presidents have tried to enact universal health legislation. Why do you think this
has proved so difficult?
c. Why is “free enterprise” so deeply embedded in the American health care system? Is it
about the brilliant strategy of the early AMA? Public preferences for private fee-based
medicine? The dominance of a particular political ideology in our national health care
politics? The perceived relative cost effectiveness of privately funded health care? A
combination of these and/or other factors?
d. Is the idea of medical free enterprise inherently inconsistent with universal
access to affordable health care? Why or why not?
Week 3 (February 11th): Health Care Financing
Reading:
Almgren, Chapter 3, The Contemporary Organization of Health Care: Health Care Finance
• Consider the following questions while reading the text. We will discuss these in class.
Additionally, pick one of these questions and write an approximately one page answer.
a. What do you believe are the three most important factors that explain why health care
expenditures in the United States are twice that of the Organisation for Economic Cooperation and Development (OECD) national average?
b. The risks of moral hazard and adverse selection are particularly problematic for
health insurance as opposed to other kinds of insurance. Why?
c. Why is it that the health insurance industry considered a universal coverage mandate
essential to the PPACA’s requirement that health insurance companies must provide
insurance to individuals with preexisting health conditions?
d. Some politicians and policy experts have suggested that the best way to save the
Medicare program from insolvency is to change it from a defined benefit program to a
defined contribution (voucher) program. What are the pros and cons to this approach?
Week 4 (February 18th): Health Care Services and Utilization
Reading:
Almgren, Chapter 4, The Contemporary Organization of Health Care: Health Care Services
and Utilization
• Consider the following questions while reading the text. We will discuss these in class.
Additionally, pick one of these questions and write an approximately one page answer.
a. The United States is one of only two OECD member states where public financing
makes up less than half of health care expenditures. What factors might explain this
anomaly?
b. Despite nearly tripling the nation’s investment in health care between the mid-1970s
and 2010, the nation’s hospital bed capacity has declined by 35% over this same
period. Is this a good thing or a bad thing? In what ways?
c. In the United States, the ratio between specialists and primary care physicians is about
2:1. In Canada the ratio between specialists and primary care physicians is almost
exactly 1:1. What are some reasons that the U.S. health care system has favored a high
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Spring 2015, Professor Parker
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ratio of specialists relative to that of Canada’s health care system? Is this a good thing
or a bad thing? Why?
d. List the mix of public and private healthcare provider organizations in the US
healthcare system. What role do each of these play in providing a social safety net?
What role should they play?
Week 5 (February 25th): Long-Term Care of the Aged and Disabled
Reading:
Almgren, Chapter 5, Long-Term Care of the Aged and Disabled
• Consider the following questions while reading the text. We will discuss these in class.
Additionally, pick one of these questions and write an approximately one page answer.
a. Almgren points out that even with modest levels of immigration to offset the low
birthrate among native-born Americans, the old age dependency ratio is projected to
increase by 58% by 2025 and by 77% by 2050, relative to 2000. As of 2012, however,
such factors as enhanced border enforcement, punitive state policies toward
undocumented immigrants, and several years of recession have resulted in near zero net
migration of undocumented immigrants from Mexico and Latin America. From the
standpoint of national long-term care policy, is this a good thing? Why or why not? Is
there a pragmatic and just approach to immigration policy that would promote the fiscal
sustainability of both long-term care financing and the long-term care labor force? If so
what would it look like?
b. Sociologist Evelyn Nakano Glenn argues that the prevalence of unpaid and low wage
caregiving among women, and in particular women of color, is attributable to a “status
obligation” to function as caregivers of dependents. According to the sociological theory,
the expectations that arise from a status obligation have both an internalized component
and an external component. Do you believe that the idea of a “status obligation” is a
plausible explanation for women, particularly women of color, providing a
disproportionate share of unpaid and low wage care?If so, what are some the social
mechanisms that might create and sustain this particular status obligation?
c. Consider the following scenario. George and Harriet are in their mid-80s. George has
had a debilitating stroke, and Harriet is at the limits of her capacity to care for him. They
have some savings and a small income from pensions and Social Security. In order to
remain together in their home, however, they require Medicaid subsidized “in-home”
long-term care services—services that the state government is proposing to eliminate in
order to meet the funding priorities in both basic and higher education. How does this
case illustrate what political philosopher John Rawls considered to be the primary moral
problem that arises when considering extreme health needs? If you were a state
legislator with the responsibility of voting on these cuts, would you vote “yea” or
“nay”? How would you explain or justify our vote to a constituent?
d. Suppose that the circumstances described in the preceding discussion question were a bit
different. Instead, let’s assume that George is a developmentally disabled adult in his
late 40s and that Harriet is his aging mother struggling to care for him. In order to do so,
she is heavily reliant on the support they receive from Medicaid subsidized “in-home”
services. The proposed state cuts described in the preceding discussion question would
also apply to this version of George and Harriet. How does this version of George and
Harriet also illustrate the moral problem of extreme health needs that Rawls described?
Does this version of George and Harriet raise different moral considerations than the
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version of the couple in the preceding question? If so, what are they? As a legislator,
would your knowledge of this case and others like it cause you to think or feel
differently about your vote compared to the situation of George and Harriet described in
the preceding discussion question?
Week 6 (March 4th): Health Care Disparities
Reading:
Almgren, Chapter 6, Disparities in Health and Health Care
• Consider the following questions while reading the text. We will discuss these in class.
Additionally, pick one of these questions and write an approximately one page answer.
a. The Institute of Medicine (IOM) defines health care disparities as differences in “the
quality of healthcare that are not due to access-related factors or clinical needs,
preferences, and appropriateness of intervention.” Almgren claims that the IOM’s
definition is (1) overly narrow and (2) in part a political definition as opposed to a
scientific one. What are some of the arguments that Almgren makes in support of these
claims? Do you agree or disagree? Explain.
b. Disparities in health and disparities in health care are distinct but related concepts. How
are health disparities and health care disparities conceptually distinct from one another
and how are they related?
c. Many highly regarded scientists argue that race is a social, not a biological construct,
which by implication would suggest that race should not be a factor in either diagnosis
or treatment. Is the patient’s race ever a legitimate factor that a clinician should consider
in diagnosis or treatment? Explain your answer.
d. Most social scientists generally define institutional racism as institutional-level
structures and processes that sustain the mechanisms of racial oppression with or
without individual-level awareness or malicious intent. Have you ever observed or
encountered this form of racism in health care? If so provide a brief description. How
would you go about pursuing change?
Week 8 (March 11th): Health Care Disparities Determinants
Reading:
Almgren: Chapter 7, Social Epidemiology: Unraveling the Social Determinants of Disparities
in Healthcare
• Consider the following questions while reading the text. We will discuss these in class.
Additionally, pick one of these questions and write an approximately one page answer.
a. What is meant by “the production function of disease?” What are some of the ways
in which it occurs? Can you cite a specific example outside of those suggested in the
book?
b. What are the strengths and weaknesses of a diabetes public health strategy for low
income individuals that focuses on prevention education?
c. According to Phelan, Link, Diez-Roux, Kawachi, and Levin (2004) educational level
has only modest protective benefits against unpreventable causes of death. By
comparison, educational level’s protective effect against preventable causes of death
is quite substantial. Why might this be? How are these findings consistent with the
central proposition of Fundamental Social Causes Hypothesis?
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d. Do you personally believe that a nation’s level of income inequality affects its
overall level of population health? If not, what are some reasons for your skepticism?
If so, what do you believe are the principal pathways through which high levels of
population income inequality are detrimental to population health?
SPRING BREAK: March 15th through 22nd
Assignment: Relax and take a walk for your health.
Week 9 (March 25th): Health Care Reform Part I
Readings:
Chapter 8, Prospects for Just Health Care System Reform: A Political and Principled Analysis
and review Chapter 1, A Primer on Theories of Social Justice and Defining the Problem of
Health Care
• Consider the following questions while reading the text. We will discuss these in class.
Additionally, pick one of these questions and write an approximately one page answer.
a. Do you believe that everyone in the United States should have some very basic rights to
health care, with or without the ability to pay?
• Why or why not?
• If you do believe that everyone should have such rights, what are those basic
rights?
b. Some advocates of universal health care coverage have suggested that the PPACA relies
on a fundamentally flawed mixed of public and private health care systems and that the
US should replace it with a single-payer model (e.g., “Medicare for All”). Defenders of
the PPACA argue that it represents the nation’s best hope for achieving both universal
health coverage and cost containment because it is the most politically viable approach.
What do you believe and why?
Week 9 (April 1st): Health Reform Part II
In Class Video: Escape Fire: The Fight to Rescue American Healthcare
Signup for comparative health care system presentations:
Students will work in teams and make presentations on healthcare systems from around the
world. They should use the readings from Johnson & Stoskopf to form the basis of their
presentations but may include any other information as long as they properly cite this
information. Each team will present two healthcare systems.
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Week 10 (April 8th): Take Home Essay Exam Due
No Reading or class for this week so you can work on your take home essay exam which is due today
via email by midnight.
Instructions and Questions: Note: There is no set page minimum or maximum for each question but
the total for all your responses should not exceed 15 to 20 double spaced pages and less is fine! Length
for length’s sake is not desirable. Writing crisply and clearly is the goal. It is acceptable to answer a
question using bullet points providing you are thorough and justify your answers. For some of these
questions, there is no one right answer. Rather, you need to think about the material we have been
reading and discussing and come up with thoughtful, well-reasoned, and factually based reasons to
justify your responses. Most importantly, try to think like health care policymaker.
You are free to look at the texts and anything else you have read. You may also discuss these
questions with your classmates to help you fine tune your thinking. It is important, however, that you
cite others’ work. If you use someone else’s idea to justify a point, you need to cite the book, article,
internet site, etc. Finally, this is intended to be a thought provoking and interesting learning experience
for you, rather than a painful exercise.
Please answer the following questions
1. What are some of the principal factors that impede access to health care in the United States?
Which do you think are the most significant and why?
2. One of the most common arguments against publically funding health care is that such financing
would inevitably lead to health care “rationing.” Proponents of publically funded health care argue
that rationing is already deeply embedded in the American health care system.
i. Are either or both claims valid? How so or why not?
3. In what ways do particular political positions you have heard or read about, either in favor of or in
opposition to the Patient Protection and Affordable Care Act (PPACA), reflect any of the five
frameworks of social justice that Almgren describes?
4. Briefly summarize what you see as the major distinctions between a psychosocial perspective on the
effects of population income inequality on population health, and a political/economic perspective
of the income inequality effects on health. How would they differ in their social policy
implications?
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Comparative Health Care Systems
Week 11 (April 15th)
•
Readings:
- Handout: Schoen ,C, Osborn, R. Squires, D., & Doty, M. D. (2013). Access, Affordability,
and insurance Complexity are often Worse In The United State Compared To Ten Other
Countries doi: 10.1377/hlthaff.2013.0879 Health Affairs, 32, NO. 12 (2013).
- Johnson & Stoskopf
 Chapter 1, Introduction to Health Systems (review if have already read)
 Chapter 2, Global Health and Disease
 Chapter 3, Global Health: Systems, Policy, and Disease
 Chapter 5, United Kingdom
•
In class video, Sick Around the World”, a Frontline PBS documentary
- If you would like to view this video again, you can find it online at:
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/
Weeks 12, 13, and 14 (April, 22nd, April 29th and May 6th)
For these weeks, students will prepare and make team presentations on other health care systems from
around the world. Each team will present two healthcare systems.
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Spring 2015, Professor Parker
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Week 15
Term Paper Due: May 13th by midnight. No class so that students can work on
papers.
Consider all the healthcare systems that we have discussed including the US System. Also consider
the problems we have explored and the videos we have seen describing existing problems and potential
solutions. Utilizing all that we have learned and any additional information that you have read and can
cite, describe the type of system that you believe would provide the greatest access to high quality
health care to the most people in the United States. If you prefer you may design a system for another
country, please discuss that with me first. Justify your choices based on the materials.
Consider all of the following as you design your system:
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•
•
•
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Funding:
- Would the system use tax dollars, pre-tax dollars from citizens, pre-tax dollars from employers,
post tax dollars and from whom?
- Would the system be public funded (tax dollars) single payer, private multi-payer, voluntary or
mandatory insurance, for profit or not-for-profit insurance or a mixture of the two, a mixture of
public and private funding?
- What role would employers play in funding?
- Would the system include co-pays, monthly premiums and if so who would pay these?
Coverage
- Beyond office visits and hospital care, what would the system cover (e.g., dental, eye care,
mental health, physical and occupational therapy)?
- Would the system cover non-western treatments such as acupuncture and herbal medicines?
- Would the system cover services that relate to but are beyond what is often considered health
care such as: Access to healthy food, exercise, massage therapy, spa visits, etc.
Emphasis/focus. Describe the balance among primary disease care, acute disease care, and
preventive care within the system and the extent to which it would focus on primary versus
specialty care.
Gatekeeping. Would you utilize gatekeepers to specialty services? Why, why not?
Organization. How would you organize health care professionals (e.g., in private practices, in
large group clinics, in hospital based clinics, a mixture of different methods)?
Prices/rates. Would you negotiate or set government fixed rates for services and pharmaceuticals?
If so what prices would you negotiate or fix and why?
Other. Feel free to include other issues you would consider when you design the system and
components you would include in it.
Limitations. Describe the greatest potential limitations of the system and how might you mitigate
them.
Important: Justify your choices. You may base your decisions on the materials we have read and
discussed in class, as well as any other articles you choose to read in health care and policy scholarly
journals, as well as, print and online news outlets. You must cite your sources.
Note. There is no set page minimum or maximum for each question but the total should not exceed 15
to 20 double spaced pages.