This is an intensive seminar on the policy and politics of health care. Its purpose is to introduce members of the seminar to the wide range of complex issues raised by this fundamental sector of a modern society, and to help participants understand the reasons, in addition to sheer complexity, that policymaking in this sector is so difficult.

Even the boundaries and definition of "health care policy" are matters of political dispute. To some, it includes virtually everything that might affect health -- and so, virtually everything. To others, including myself, it should only include those policies that involve deployment of societal resources to treat or prevent disease. But even that more narrow definition includes a very wide range of activities, from federal-government-sponsored scientific research, to national medical insurance for the elderly (Medicare), to federal/state medical insurance for the poor (Medicaid) and cooperation to track public health threats (CDC surveillance), and finally local government provision of some health services (public hospitals) and regulation of health-related behaviors (the controversy over bathhouses in San Francisco and New York). While each such issue has its own separate politics, ultimately they are linked in very practical ways. A public health epidemic that is not stopped by public health officials at the local level turns into a Medicaid expense; research progress on AIDS or Alzheimer's can lead to new expenses for Medicaid or Medicare.

Because of the wide range of issues involved, health care politics exhibits a similarly wide range of political conflicts. For some issues, a politics of expertise and calculation, based on budgetary and economic arguments, frequently dominates. That is true of much of Medicare politics, which is mainly about cost control and its techniques. On other issues, such as AIDS, the emotional stakes of fear and interpersonal relations are much closer to the surface, and more obviously affect policymaking. I have organized the course to look at both kinds of issues, both because they exist and for normative reasons. My personal bias is that it is too easy to become caught up in the kind of Washington policy elite debate that loses sight of the great emotional salience of health care policy. Ultimately, the stakes even in seemingly technical Medicare finance debates involve whether individuals will be exposed to pain and unnecessarily early death.

I am asking students to purchase four books for the course. They are:

Thomas E. Mann and Norman J. Ornstein, eds.: Intensive Care: How Congress Shapes Health Policy. This book should serve as an introduction to national policymaking processes about health care.

Randy Shilts, And the Band Played On: Politics, People, and the AIDS Epidemic. Yes, it's long, but it's a very good, though sometimes horrifying, read. I apologize if some participants, for personal reasons, find this story hard to take. I know of no better introduction to both the non-national side of health policy, and the extent to which other agendas can influence health policy decisions.

Michael S. Sparer, Medicaid and the Limits of State Health Care Reform. The role of the states has to be a subject of any health policy course, especially one taught in a state that has been quite active and innovative about expanding coverage and structuring the medical market. This book provides a look at state capacities and variations while also providing a guide to Medicaid policy.

Joseph White, Competing Solutions: American Health Care Proposals and International Experience. This book covers two subjects, comparative international health care policy, and managed competition theory, and I would be abnormally modest if I did not think it did so reasonably well. I argue one has to understand both these subjects to understand the policy side of the Clinton Health Security Act debacle.

In addition to these readings, I am assigning articles that will be placed on short-term reserve at the library. They are listed in the class schedule that follows. Rather than make you fill out a separate card for each of many small articles, I am supplying them to the library in groupings. So in the listings below, I list each article within its group. For week 5, for example, there will be two folders on reserve.

Requirements

Each student will be expected to do all the reading due for each class session. This is important in a small seminar in order to facilitate high-quality class discussion, and is especially important in order to discourage your professor from lecturing too much. Therefore, each week I will provide a question about the next week's reading and ask you to write a two-page paper in response to the question. I would like you to deliver those papers to my office by noon on each class day, so that I may see what you have concluded or are puzzled about before the class discussion.

These papers will determine 25 percent of your class grade, and other aspects of class participation will count for 10 percent. The rest will be based on a seminar paper, addressing a topic of your choice about health care policy and politics.

We will need to work together to define your individual topics in a way that will enable you to write manageable and interesting papers. I expect a typical paper to be about 30 double-spaced pages. I would like to discuss your possible topics with you by Wednesday, September 24, and to have a three-page prospectus by the following Monday, September 29. The finished papers will be due on Tuesday, November 18.

Schedule

The following schedule lists the readings due for each week.

Week 1 Introduction, No Readings Required

Week 2 Policy Areas

White, Competing Solutions Chapters 1-2;
(1) Mark A. Peterson, "Health Care Into the Next Century," David M. Cutler, "Restructuring Medicare for the Future", Chris Foreman, "Visible Victims";
(2) Health Affairs Symposium: "The Safety Net vs. the Market: Is the Safety Net in Crisis?"

Week 3 National Institutions

Mann and Ornstein, Intensive Care, Chapters 1-6;
(1) Stephen D. Nelson, "A Brief History of the Development of the National Institutes of Health", and Pamela J. Smith, "A Summary of a Case Study of the National Cancer Institute";
(2) Martin A. Levin, "The Day After an AIDS Vaccine is Discovered: Management Matters", Deborah A. Stone, "The Doctor as Businessman: The Changing Politics of a Cultural Icon";
(3) Frank R. Baumgartner and Jeffery C. Talbert, "From Setting a National Agenda on Health Care to Making Decisions in Congress"; Theodore R. Marmor, "A Summer of Discontent: Press Coverage of Murder and Medical Care Reform".


Week 4 Issues in National Health Care Reform

White, Competing Solutions, Chapters 3-10, Appendix

Week 5 The Failure of National Health Insurance

Mann and Ornstein, Intensive Care, Chapters 7, 8;
(1) Theda Skocpol, "The Rise and Resounding Demise of the Clinton Plan," James J. Mongan, "Anatomy and Physiology of Health Reform's Failure," Margaret Weir, "Institutional and Political Obstacles to Reform," Uwe E. Reinhardt, "Turning Our Gaze From Bread and Circus Games";
(2) 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", Steven Rathgeb Smith, "The Role of Institutions and Ideas in Health Care Policy"

Week 6 The Plague

Shilts, And the Band Played On, Prologue through Part 5

Week 7 AIDS Part 2

Shilts, And the Band Played On, Part VI through Afterword;
(1) Jane Kramer, Bad Blood

Week 8 States and Federalism

Sparer, Medicaid and the Limits of State Health Care Reform;
(1) Oliver and Paul-Shaheen, "Translating Ideas into Actions: Entrepreneurial Leadership in State Health Care Reforms"

Week 9 "Experts" and Their Uses

(1) Donald W. Light, "The Rhetoric and Realities of Community Health Care: The Limits of Countervailing Powers to Meet the Health Care Needs of the Twenty-first Century";
(2) Ashmore, Mulkay, and Pinch, "Health and Efficiency," pp. 60-114. (Note: You may choose to read pp. 86-114 first);
(3) Joseph White, "Medical Savings Accounts: Fact Versus Fiction";
(4) Health Care Delivery Systems Division of the Minnesota Department of Health, "Medical Savings Accounts: A Feasibility Study for the Minnesota Legislature," Michael Tanner, "Medical Savings Accounts: Answering the Critics"

Week 10 Discussion of Student Papers-in-Progress

No assigned reading