Current Issues in Health Policy (P11.2836)
Michael Birnbaum
Adjunct Associate Professor
Wagner School of Public Service
mb187@nyu.edu; 212.494.0793
Spring 2009
Monday: 6:45 – 8:25 pm
194 Mercer Street
Room # 305
Overview
This course is an introduction to some of today’s major health policy issues. The first half
of the course examines the health insurance system, including the uninsured, the
employer-based model, and the major public programs—Medicare and Medicaid. The
second half of the course examines the health care delivery system, considering issues
such as variation in medical practice, the quality of care, and malpractice reform.
Throughout the course we will consider ongoing policy debates and, where possible, policy
reforms that are under consideration or in implementation.
Attendance, preparation, and class participation
Students are expected to:
• Attend every class;
• Complete assigned readings before each class;
• Make informed contributions to class discussion.
Office hours
I will be available on the Mondays when class is held, from 5:00 to 6:00 pm, in the Puck
Building’s third floor adjunct offices.
In addition, students should feel free to email me (mb187@nyu.edu) with questions about
readings, assignments, and other course-related matters. Depending on the matter, we
will address it either via email, a scheduled phone call, or an in-person meeting.
Grading
The final grade will be determined as follows:
• Class participation:
20 %
• Policy memo #1:
40 %
• Policy memo #2:
40 %
Policy memos
For students new to writing policy memos, this assignment represents an opportunity to
explore a writing style that is expected in most professional policy analysis positions.
When compared to the essays that many classes require, policy memos have core
similarities as well as key differences. The similarities include the expectation that the
content will be substantive and analytic, the writing clear and precise, and the organization
tight. As with essays, it is vital that all data – as well as ideas that are not original – are
cited clearly to the appropriate source. The differences between policy memos and essays
– some obvious, others more subtle – will be discussed in class, with the aid of examples.
Memo # 1: due March 31
You are the health policy advisor to a United States Senator who has just received a
coveted seat on the Finance Committee. This committee has jurisdiction over Medicare
and Medicaid, as well as federal tax policy. The Senator has asked you to prepare her for
an upcoming hearing. In a memo of no more than four single-spaced pages, explain the
biggest problems facing Medicare and Medicaid, as well as these problems’ key
similarities and differences. Please keep in mind two important things. First, your boss
knows the basics about these two important programs, so dive right into your analysis
without wasting valuable space on background and historical context. Second, you are a
policy analyst, not a political consultant, so do not critique policies on political grounds.
Policy memo #2: due May 11
You are the health policy advisor to a United States Senator who has an eye on running
for President in 2012. Your boss wants to craft legislation that changes how health
services are delivered and improves the quality of medical care. Because the Senator
does not have a seat on the Finance Committee, the bill must not deal principally with
Medicare or Medicaid, but with the delivery system as a whole. Like most of his
colleagues, your boss does not know where to begin on this complex set of issues. In a
memo of no more than four single-spaced pages, make the case for the policy proposal
you believe your boss should champion and explain its likely impacts.
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Session 1: January 26
Introduction
We will discuss the course’s key themes and goals, as well as the requirements and
expectations. We will then consider some introductory material on the financing,
organization, and delivery of health care in the United States.
No Class on February 2
Session 2: February 9
Health insurance coverage: Does it matter? Who are the uninsured?
We consider the importance of coverage, the composition of the uninsured, and the forces
that shape which people—and how many—go without coverage.
Institute of Medicine, Coverage Matters: Insurance and Health Care. National Academy
Press: 2001. Executive Summary (pp. 1-18).
Institute of Medicine, Care Without Coverage: Too Little Too Late. National Academy
Press: 2002. Executive Summary (pp. 3-16).
Institute of Medicine, A Shared Destiny: Community Effects of Uninsurance. National
Academy Press: 2003. Executive Summary (pp. 1-14).
Kaiser Family Foundation, “The Uninsured: A Primer.” Kaiser: 2008.
John Holahan and Allison Cook. “The U.S. Economy and Changes in Health Insurance
Coverage, 2000-2006.” Health Affairs: February 20, 2008.
No Class on February 16
Session 3: February 23
Employer-based coverage
We focus on the employer-based model’s emergence, its implications for low-wage
workers, and its significance for the public health insurance programs that complement it.
Uwe Reinhardt, “Employer-Based Health Insurance: A Balance Sheet.” Health Affairs:
1999, 18(6):124-132.
Steffie Woolhandler and David Himmelstein, “Paying for National Health Insurance – And
Not Getting It.” Health Affairs: 2002, 21(4):88-98.
Alain Enthoven and Victor R. Fuchs, “Employment-Based Health Insurance: Past, Present,
And Future.” Health Affairs: November/December 2006.
Sara Collins, “Whither Employer-Based Health Insurance?” Commonwealth Fund: 2007.
Sherry Glied and Bisundev Mahato, “The Widening Health Care Gap between High- and
Low-Wage Workers.” The Commonwealth Fund: May, 2008.
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Session 4: March 2
Medicare I: introduction and overview
We consider Medicare’s current structure and the roles it plays in providing coverage to
the elderly and disabled. We focus on Medicare’s benefits package, including the new
prescription drug benefit as well as the absence of long-term care coverage.
Karen Davis and Sara Collins, “Medicare at 40.” Health Care Financing Review: 20052006, 27(2).
Bryan Dowd et al., “Fee-for-service Medicare in a Competitive Market Environment.”
Health Care Financing Review: 2005-2006, 27(2).
Mark Santangelo, “Historical Perspective on Adding Drugs to Medicare.” Health Care
Financing Review: 2005-2006, 27(2).
Kaiser Family Foundation, “The Medicare Prescription Drug Benefit” (fact sheet). Kaiser:
2007.
Judith Feder et al., “Long-Term Care in the United States: An Overview.” Health Affairs,
2000: 19(3):40-56.
Georgetown University Long-Term Care Financing Project, “Medicare and Long-Term
Care” (fact sheet.) Georgetown: 2007.
Session 5: March 9
Medicare II: budget issues and options for reform
We focus on Medicare’s long-term budget constraints and consider the major issues
relevant to a long-term restructuring of the Medicare program.
Richard Foster and Kent Clemens, “Medicare Financial Status, Budget Impact, and
Sustainability—Which Concept is Which?” Health Care Financing Review: 2005-2006,
27(2).
Karen Davis et al., “Medicare Extra: A Comprehensive Benefit Option For Medicare
Beneficiaries.” Health Affairs web exclusive, 2005.
Marilyn Moon, “Medicare Means-Testing: A Skeptical View.” Health Affairs web exclusive,
2004.
Timothy Gronniger and Robert Sunshine, “Medicare Advantage: Private Health Plans in
Medicare.” Congressional Budget Office: 2007.
Congressional Budget Office. “Financing Long-Term Care for the Elderly,” CBO: 2004.
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March 16: No Class due to Spring Recess
Session 6: March 23
Medicaid I: introduction and overview
We examine the structure and responsibilities of the nation’s most complex public
program, with specific attention to the challenge of filling the gaps left by Medicare.
Diane Rowland, “Medicaid at 40.” Health Care Financing Review: 2005-2006, 27(2).
Judith Moore and David Smith, “Legislating Medicaid: Considering Medicaid and Its
Origins.” Health Care Financing Review: 2005-2006, 27(2).
Alan Weil, “There’s Something about Medicaid,” Health Affairs, 22(1), 2003.
Robert Hurley and Stephen Somers, “Medicaid and Managed Care: A Lasting
Relationship?” Health Affairs: 22(1), 2003: 77-88.
Judith Kasper et al., “Long-Term Services and Supports: The Future Role and Challenges
for Medicaid. Kaiser: 2007.
Session 7: March 30
Medicaid II: how the rubber hits the road
Using New York as a case study, we assess Medicaid’s performance in achieving program
goals and meeting its considerable challenges.
Michael Birnbaum, “Medicaid in New York: A Primer (Revised and Updated 2008).”
Medicaid Institute at United Hospital Fund: 2008.
Access New York: the State’s application for Medicaid (and SCHIP).
Application for Disaster Relief Medicaid (September 24, 2001 – January 31, 2002).
Kate Lawler, “Reality Check: A View from the Front Lines of Public Health Insurance
Enrollment,” Children’s Aid Society: March 2003.
Andrea Cohen et al., “Streamlining Renewal in Medicaid and SCHIP: Strategies from
Other States and Lessons for New York.” United Hospital Fund: 2008.
Michael Sparer, “Medicaid Managed Care Reexamined.” Medicaid Institute at United
Hospital Fund: 2008.
Michael Birnbaum and Leslie Powell, “Managing Care for High-Cost Elderly Duals: A
Challenge for Medicaid.” Medicaid Institute at United Hospital Fund: 2008.
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Session 8: April 6
Expanding health insurance coverage
We examine current proposals to cover the uninsured, both at the state and federal level.
Danielle Holahan et al., “A Blueprint for Universal Health Insurance Coverage in New
York.” United Hospital Fund: 2006.
John E. McDonough et al., “Massachusetts Health Reform Implementation: Major
Progress and Future Challenges.” Health Affairs: June 3, 2008.
Jack Hadley et al., “Covering the Uninsured in 2008: Current Costs, Sources of Payment,
And Incremental Costs.” Health Affairs: August 25, 2008.
Senator Max Baucus, “Call to Action: Health Reform 2009.” U.S. Senate Finance
Committee, November 2008 (especially chapters 2 and 3).
Edwin Park, “An Examination of the Wyden-Bennett Health Reform Plan: Key Issues in a
New Approach to Universal Coverage.” Center on Budget and Policy Priorities:
September 2008.
Additional and/or updated materials on current federal proposals may be added.
Session 9: April 13
Medical practice and health policy
We explore variation in medical practice and we consider its causes and implications for
policy makers and health care providers.
John Wennberg, “Dealing with Medical Practice Variations: A Proposal for Action,” Health
Affairs: 1984, 3(3).
John Wennberg et al., “Care of Dying Patients in the Best US Hospitals,” BMJ: 2004.
Elliot Fisher et al. The Implications of Regional Variation in Medicare Spending – Part 1.
Annals of Internal Medicine: 2003.
Elliot Fisher et al. The Implications of Regional Variation in Medicare Spending – Part 2.
Annals of Internal Medicine: 2003.
Darrell J. Gaskin et al., “Do Hospitals Provide Lower-Quality Care to Minorities than to
Whites?” Health Affairs: 2008, 27(2).
Paul L. Hebert et al., “When Does a Difference Become a Disparity? Conceptualizing
Racial and Ethnic Disparities in Health.” Health Affairs: 2008, 27(2).
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Session 10: April 20
Quality I: Measuring the quality of health care
We consider what many analysts have called the health policy issue of the 21st century.
Institute of Medicine, To Err Is Human: Building a Safer Health System. National Academy
Press: 2000. Executive Summary.
Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st
Century. National Academy Press: 2001. Executive Summary.
Institute of Medicine, Preventing Medication Errors. National Academy Press: 2006.
Executive Summary.
Elizabeth McGlynn, “The Quality of Health Care Delivered to Adults in the United States,”
New England Journal of Medicine: June 26, 2003, 348(26):2635-2645.
Donald Berwick, “Escape Fire: Lessons for the Future of Health Care,” Commonwealth
Fund: November 2002.
Session 11: April 27
Quality II: Improving the quality of health care
Through a case study approach, we consider an ongoing approach to improving key health
outcomes in New York.
Peter Buerhaus, “Is Hospital Patient Care Becoming Safer? A Conversation with Lucian
Leape,” Health Affairs: 2007.
Robert Galvin and Elizabeth McGlynn, “Using Performance Measurement to Drive
Improvement: A Road Map for Change,” Medical Care: January 2003 Supplement,
41(1):47-59.
Brian S. Koll et al., “The CLABs Collaborative: A Regionwide Effort to Improve the Quality
of Care in Hospitals.” The Joint Commission Journal on Quality and Patient Safety:
December 2008.
Greater New York Hospital Association and United Hospital Fund: “Quality Collaborative”
Newsletter: Summer 2008, Fall 2008, and Winter 2009.
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Session 12: May 4
Medical malpractice: the role of legal system in health care
We examine the effectiveness of the malpractice system and consider options for reform.
MM Mello et al., “The New Medical Malpractice Crisis,” NEJM: 2003, 348(23):2281-4.
MJ Hatlie and SE Sheridan, “The Medical Liability Crisis of 2003: Must We Squander the
Chance to Put Patients First?” Health Affairs: 2003, 22(4).
WM Sage. “Medical Liability and Patient Safety,” Health Affairs: 2003, 22(4).
C Struve. “Improving the Medical Malpractice Litigation Process,” Health Affairs: 2004,
23(4):33-41.
CV Liebman and CS Hyman, “A Mediation Skill Model to Manage the Disclosure of Errors
and Adverse Events to Patients,” Health Affairs: 2004, 23(4):22-32.
DM Studdert et al., “Are Damages Caps Regressive? A Study of Malpractice Jury Verdicts
in California,” Health Affairs: 2004, 23(4):54-67.
Session 13: May 11
Prescription drugs and the pharmaceutical industry
We consider some of the major public policy issues related to prescription drugs.
B Als-Nielsen et al., “Association of Funding and Conclusions in Randomized Drug Trials,”
JAMA: 2003, 290:921-928.
NK Choudhry et al., “Relationship between Authors of Clinical Practice Guidelines and the
Pharmaceutical Industry,” JAMA: 2002, 287:612-617.
R Roberts, “Pediatric Drug Labeling, JAMA: 2003, 290:905-11.
P Budetti, “Ensuring Safe and Effective Medication for Children,” JAMA: 2003, 290:950951.
MT Gahart et al., “Examining the FDA's Oversight of Direct-to-Consumer Advertising,”
Health Affairs web exclusive: February 26, 2003.
JS Weisman, “Consumers' Reports on the Health Effects of Direct-to-Consumer Drug
Advertising,” Health Affairs web exclusive: February 2003.
TW Croghan, “The Medicine Cabinet: What’s in It, Why, and Can We Change the
Contents?” Health Affairs: 2004, 23(1):23-33.
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