School of Public Policy

University of Maryland, Baltimore County

Spring 2024

PUBL 618: Issues in Health Care Finance and Service Delivery

Time and Place: Tuesday, 4:30 - 7:00 p.m.

PUBL 438

Instructor: Nancy A. Miller

nanmille@umbc.edu
Office hours: by appointment

Should you need services or accommodations due to a disability to fully participate in the class,
please speak with us or contact the Office of Student Support Services, Phone No.: (410) 455 –
2459; TTY: (410) 455 – 3233.

Course Description

The purpose of this course is threefold: 1) to provide an overview of the concepts,

principles, and practices in financing health care services in the U.S.; 2) to understand the
relationship between public and private sector financing of health care; and 3) to become
sensitive to the complexities of U.S. health services finance, payment, and service delivery,
including health care reform efforts.

Course Objectives

After completing this course, you should be better able to:

1. Describe the sources of private and public financing of health care services in the U.S.

2. Describe the current private and public sector insurance programs, as well as reform
issues.

3. Understand the relationship between insurance coverage and access to and use of services.

4. Describe additional factors that influence access to and use of health services.
1
5. Describe and evaluate the impact of trends in health care financing, payment, and service
delivery.

6. Evaluate the impact of recently passed, as well as proposed health care legislation on key
features such as increased coverage, costs and quality.

7. Demonstrate proficiency in presenting material through written and oral analyses.

Requirements

1. Complete required readings before class and participate in discussion of them during
class sessions.

2. Complete “discussion questions” posted via Blackboard’s discussion board related to

specific readings.

3. Develop a health care reform proposal and present the proposal in class. The
proposal will follow the form of a policy analysis.

Grading

Discussion questions, 6 posts; 5 points per discussion 30 percent

Policy analysis Part 1 analysis and presentation 10 percent
Policy analysis and presentation: 45 percent
Class participation: 15 percent

Course Materials

Readings will be posted on BlackBoard or can be retrieved from the internet.

Course Outline and Readings

January 30 Course Introduction

February 6 Case, A. & Deaton, A. (2022). The Great Divide: Education, Despair and Death.
Annual Review of Economics, 14:1-21.
Fashaw-Walters, S.A. & McGuire, C.M. (2023). Proposing a Racism-
Conscious Approach to Policy Making and Health Care Practices. Health Affairs,
42(10):1351-1358.

2
 Agency for Healthcare Research and Quality (2023). Executive
Summary. National Healthcare Quality and Disparities report.

Pourat, H., et al. A Review of Health Center Efforts to Address the Social
Determinants of Health: A Systematic Review. Medical Care Research and
Review, online first.

Discussion: President Biden will make his State of the Union Address
on March 7, 2024. What one health care issue would you suggest that
President Biden speak to as part of his address?

February 13 Overview of National Health Care Expenditures

Hartman, M. et al. (2024). National Health Care Spending in 2022:

Growth Similar to Prepandemic Rates. Health Affairs, 43(1), Online December
13, 2023.

Weaver, M.R. et al. (2022). Health Care Spending Effectiveness

Estimates Suggest that Spending Improved Health Care from 1996-2016. Health
Affairs, 41(July).

Shrank, W. et al. (2021). Health Costs and Financing: Challenges and

Strategies for a New Administration. Health Affairs, 40(2):1-8.

Gaffney, A. et al. (2023). Century Long Trends in the Financing and

Ownership of American Health Care. Milbank Quarterly, June:1-24.

Discussion: The health care sector of the U.S. gross domestic product
was 17.3% in 2022. Is there a reason to be concerned about this level of
health care spending? Why or why not?

February 20 Trends in Telehealth and Health Information Technology

Yael Harris, Ph.D. (’02)

CEO
Laurel Health Advisors

Center for Connected Health Policy. What is Telehealth, available at:

https://www.cchpca.org/what-is-telehealth/
 Note this is a website led by a federally funded entity. The descriptions of
different components of telehealth are short video clips (about 2 min) so more

3
 engaging than an academic article and the text is written in plain language so less
technical than peer reviewed literature
Shaver J. The state of telehealth before and after the COVID-19 pandemic.
Primary Care. 2022 Dec; 49(4): 517-530
World Economic Forum. 5 innovations that are revolutionizing global healthcare.
Feb 22, 2023, available at: https://www.weforum.org/agenda/2023/02/health-
future-innovation-technology/

February 27 Evidence on the Role of Health Insurance for Health Care Access and Outcomes

Woolhander, S. & Himmelstein, D. (2017). The Relationship of Health

Insurance and Mortality: Is Lack of Insurance Deadly? Annals of Internal
Medicine, June 27.

Hadley, J. (2003). Sicker and Poorer – The Consequences of Being

Uninsured: A Review of the Research on the Relationship between Health
Insurance, Medical Care Use, Health, Work, and Income. Medical Care
Research and Review, 60(2):3S-75S.

March 5 Private Insurance—Employer Sponsored Insurance

Kaiser Family Foundation and Health Research and Educational Trust. (2023).
2023 Employer Health Benefits Survey. Summary and Selected chapters.

Claxton, G. et al. (2023). Health Benefits in 2023: Premiums Increase with

Inflation and Employer Coverage in the Wake of Dobbs. Health Affairs,
42(11):1606-1615.

Meiselbach, M.K. et al. (2024). Enrollment Trends in Self-funded Employer

Sponsored Insurance, 2015 and 2021. Health Affairs, 43(1).

Norris, H.C. et al. (2022). Utilization Impact of Cost Sharing Elimination for
Preventive Services: A Rapid Review. Medical Care Research and Review,
79(2):175-197.

Mauzurnko, O., et al. (2022). The Impact of Narrow and Tiered Networks on
Access, Quality and Patient Steering: A Systematic Review. Medical Care
Research and Review, 79(5):607-617.

Discussion: What one change would you recommend to the employer based
insurance system and why?
4
March 12 Private Insurance—Individual Market and State-Based Exchanges

Gabel, J.R., Pickreign, J. & McDevitt, R. (2011). The Individual Insurance

Market Before Reform: Low Premiums and Low Benefits. Medical Care
Research and Review, 68(5):594-606.

Chen, W. & Page, T.F. (2020). Impact of Health Plan Deductibles and Health
Insurance Marketplace Enrollment on Health Care Experiences. Health Affairs,
39(5):483-497.

Sinaiko, A.D., et al. (2022). Understanding Consumer Experiences and Insurance

Outcomes Following Plan Disenrollment from the Non-group Insurance Market.
Medical Care Research and Review, 79(1):36-45.

Makhoul, A.E. et al. (2023). Patient Cost Exposure and Use of Preventive Care
among ACA-Compliant Individual Plans. Health Affairs, 424):531-536.

Discussion: President Biden has proposed that a public option be added to

the state-based market place exchanges. Do you agree or disagree with this
proposal? Why or why not?

March 19 Spring break

March 26 Presentation of Part 1, policy analysis

April 2 Medicaid

Chris Truffer
Deputy Director
Office of the Actuary
Centers for Medicare and Medicaid Services

Klemm, J. Medicaid Spending: A Brief History. Health Care Financing Review,

22(1):105-112, 2000.

Klees, B.S., Eckstein, E.T. & Curtis, C.A. (2023). Brief Summaries of Medicare
and Medicaid. November 1, 2023.

April 9 The Affordable Care Act Medicaid Expansion

Semprini, J., et al. (2021). Effects of Medicaid Expansions on Health

After Five Years. Medical Care Research and Review, online first.
5
 Lee, H. & Porell, F. (2020). The Effect of the Affordable Care Act
Medicaid Expansion on Disparities in Access to Care and Health Status. Medical
Care Research and Review, 77(5):461-473.

Decker, S. et al. (2022). Eligibility for and Enrollment in Medicaid among

Non-elderly Adults after the Implementation of the Medicaid Expansion.
Medical Care Research and Review, 79(1):125-132.

Dong, X. & Miller, N.A. (2023). The Effect of the Medicaid Expansion under the
Affordable Care Act on Health Insurance Coverage, Health Care Access and Use
for People with Disabilities: A Scoping Review. Journal of Disability Policy
Studies, on-line first.

April 16 Medicaid—Some issues

Spivack, S.M. et al. (2021). Avoiding Medicaid: Characteristics of Primary Care

Practices with no Medicaid Revenue. Medical Care Research and Review,
40(1):98-104.

Fox, A.M. et al. (2020). Trends in State Medicaid Eligibility, Enrollment Rates
and Benefits. Health Affairs, 39(11):1909-1916.

Mahotra, N.A., et al. (2021). Medicaid’s EPSDT Benefit as an Opportunity to

Improve Pediatric Screening for the Social Determinants of Health. Medical
Care Research and Review, 78(2):87-103.

Daw, J.R. (2023). The Health and Social Needs of Medicaid Beneficiaries in the
Postpartum Year: Evidence from a Multistate Survey. Health Affairs,
42(11)1575-1585.

Ku, L. (2023). Medicaid and SNAP Advance Equity but Sometimes have
Hidden Racial and Ethnic Barriers. Health Affairs, 42(10):1347-1350.

Discussion: The participation of physicians in the Medicaid program is an

ongoing concern, and can limit beneficiaries’ access to care. What one
change to the Medicaid program would you propose to address this issue?

April 23 Medicare Overview

Klees, B.S., Eckstein, E.T. & Curtis, C.A. (2023). Brief Summaries of Medicare
and Medicaid. November 1, 2023.

6
 Medicare Payment Advisory Commission (MEDPAC). 2023. Report to
Congress: Medicare Payment Policy. Executive Summary.

April 30 Medicare – Some Issues

Jason Petroski, Ph.D. (08) (Invited)

Division of Delivery System Demonstrations
Center for Medicare and Medicaid Innovation
Centers for Medicare and Medicaid Services
Beneficiary Plan Selection for Medicare Advantage and Part D

Markowitz, et al. (2021). The Medicare Advantage Quality Bonus Program has
not Improved Plan Quality. Health Affairs, 40(12):1918-1925.

Agarwal, R. et al. (2021). Comparing Medicare Advantage and Traditional

Medicare: A Systematic Review. Health Affairs, 40(6):937-944.

Park, S. et a. (2022). Association of Medicare Advantage Star Ratings with

Racial and Ethnic Disparities in Hospitalizations for Ambulatory Care Sensitive
Conditions. Medical Care, 60(12):872-879.

Foster, R.S. and Clemens, M.K. (2005-2006). Medicare Financial Status, Budget
Impact, and Sustainability – Which Concept is Which? Health Care Financing
Review, 27(2):127-140.

Koma, J.W. (2023). Access Problems and Cost Concerns of Younger Medicare
Beneficiaries Exceeded those of Older Beneficiaries in 2019. Health Affairs,
42(4):470-478.

Medicare Payment Advisory Commission (MedPAC). 2020. Realizing the

Promise of Value-Based Payment in Medicare. Report to Congress: Medicare and
the Health Care Delivery System. Chapter 1.

Discussion: The Medicare Payment Advisory Commission has proposed that

the Medicare program move to a system of value-based purchasing. Do you
agree with this proposal? Why or why not?

May 7 Policy Analysis Presentations

May 14 Policy Analysis Presentations

May 23 Policy Analysis due

7
Discussion posts

Each discussion post is worth 6 points. You lose 1 point if you do not post your comment by the
requested time, 1 point if you do not reply to other posts by the requested time, and 1 point if
you do not reply to the requested number of other student responses.

Written Assignments

Health Care Reform

A Policy Analysis

Please prepare a policy analysis of a potential health care reform. This can focus on any health
related topic of your choosing. Your policy analysis should contain the follow components:

Part 1
1. Problem definition
2. Rationale for public intervention
3. Model or variables to be manipulated

Part 2
4. Criteria for policy evaluation
5. Alternative policy(ies), including a discussion of the status quo

Part 3
6. Comparison of alternatives by criteria
7. Recommendation

More specifically:

1. Define and describe the problem, including discussion of any supporting data (trend data,
one-time data, etc.) that you have available.

2. Define the rationale for public (government) intervention, based on efficiency concerns
(e.g., market imperfections and/or failures) and/or other criteria such as equity concerns.

3. Model your problem, to the extent that you have ideas about a model (e.g., Andersen’s
access model, Donebedian’s framework for quality of care). In particular, what are
manipulable (policy) variables that might impact your problem?

4. Identify and discuss at least two alternative policies. You should briefly describe how
you identified these alternatives.
8
5. Define what you perceive to be a “do nothing” strategy.

6. Define and discuss your criteria for policy evaluation, including some discussion of how
these criteria were derived. For each criterion identified in Part 2, you should provide a
definition of the criterion, and discuss, if possible, how it is being measured.

7. For each alternative policy, including the “do nothing” policy, evaluate it on each
criterion you identified in Part 2. You should be certain to systematically apply your
evaluation criteria to each policy alternative. You are not required to, but you may find
it helpful to develop a matrix of criteria and alternative policies. Please review Weimer
and Vining’s discussion of multi-goal analysis as you conduct this comparison.

8. Based upon your evaluation, provide a recommendation. This may include

recommending “the status quo” or one or more alternatives.

Guidelines for Final Paper

Your final paper should include the following:

Definition of the problem

Rationale for public intervention
Model of the problem that includes an identification of manipulable variables
Discussion of evaluation criteria, including method of generation
Discussion of policy alternatives, including a description of the alternatives and a
discussion of how the alternatives were derived
Comparison of the alternative policies on the evaluation criteria
Recommended policy, and a discussion of the recommendation
Discussion of potential implementation issues

1. Prepare a 2-page Executive Summary. It can be no longer than 2 pages and it should
include everything you think the policy decision maker needs to know about your
analysis, on the assumption that the policy maker may not read the analysis (although
her/his staff, the public, advocates, etc.) will.

2. The paper should include references and sources, particularly to document your problem
statement. Please follow American Psychological Association guidelines.

3. The paper should be 16-20 pages, doubled spaced, not including the Executive Summary.
It is due in May 23, 4:30 pm.

9
 Policy Analysis Presentation Guidelines

Your presentation should be no longer than 15 minutes, allowing an additional 5 minutes

for questions. Imagine that you have been asked to present your analysis to your client.
You have 15 minutes – what should the client hear from you?

Your presentation may include, but is not required to include, the use of handouts and
overheads.

10
 ACADEMIC INTEGRITY: RIGHTS AND RESPONSIBILITIES OF STUDENTS
IN THE DEPARTMENT OF PUBLIC POLICY

By enrolling in this course at UMBC, each student assumes the responsibilities of an active
participant in UMBC’s scholarly community in which everyone’s academic work and behavior
are held to the highest standards of honesty. Cheating, fabrication, plagiarism, and helping
others to commit these acts are all forms of academic dishonesty, and they are wrong. Academic
misconduct could result in disciplinary action that may include, but is not limited to, a failing
grade for the assignment, a failing grade for the course, suspension or dismissal. The Policy and
Procedures for Graduate Student Academic Misconduct is available at
http://www.umbc.edu/gradschool/procedures/misconduct.html.

Of particular concern is plagiarism. Plagiarism is defined as “taking and passing off as one’s
own the ideas, writings, etc., of another” (Webster, 1983). In other words, plagiarism is theft of
another’s words and ideas. It constitutes serious academic dishonesty. Plagiarism can result
from a student’s failure to cite a source (e.g., of the ideas, writings, etc., of another that the
student uses in his or her paper) or failure to appropriately block or use quotation marks (and an
appropriate source citation) around directly quoted material.

This policy does not distinguish between intentional and inadvertent plagiarism. Nor does it
distinguish between “drafts” and final submissions. Clearly, intentional plagiarism is a serious
offense. Some students may feel, however, that inadvertent plagiarism is not a serious offense.
It is – for at least two reasons. First, it is difficult (some might say impossible) to distinguish
between intentional and inadvertent plagiarism. Second, inadvertent plagiarism suggests that
students either have not paid attention to this policy or are willing to submit work that is
carelessly and sloppily completed. In either event, plagiarism will be appropriately punished if
it is found in any work for this course.

All students in the School of Public Policy are required to read and be familiar with the
following:

UMBC Policies and Procedures

· Statement of Values for Student Academic Integrity at UMBC
http://www.umbc.edu/provost/integrity/Honorcode.htm
· Policy and Procedures for Student Academic Misconduct
http:/www.umbc.edu/gradschool/procedures/misconduct.html

What Is Plagiarism and How to Avoid It

· A.O. Kuhn Library, “Avoid Plagiarism: Give Credit To Those Who Deserve It, Including
Yourself” (http://aok.lib.umbc.edu/reference/plagiarism.php3)
· The Writing Center at the University of Wisconsin-Madison, “Quoting and Paraphrasing
Sources” (http://www.wisc.edu/writing/Handbook/QuotingSources.html)
· The Writing Place at Northwestern University, “Avoiding Plagiarism”
11
(http://www.writing.northwestern.edu/tips/plag.html)

· A.O. Kuhn Library, “Citing Sources”

http://aok.lib.umbc.edu/reference/BI/styleguids.php3
(Note: This website includes a link to a guide for citing internet sources)
· The Writing Center at the University of Wisconsin-Madison, “Citing References in Your
Paper”
http://www.wisc.edu/writing/Handbook/Documentation.html

We encourage you to bring any questions you might have regarding the meaning and importance
of academic integrity, what plagiarism is and how to avoid it, and citation styles to faculty
members in the department.

UMBC Policies and Resources, Fall 2020

(Updated August 21, 2020)

 Accessibility and Disability Accommodations, Guidance and Resources

 Sexual Assault, Sexual Harassment, Gender Based Violence and Discrimination

 Pregnancy

 Religious Observances & Accommodations

 Hate, Bias, Discrimination and Harassment

Accessibility and Disability Accommodations, Guidance and Resources

Accommodations for students with disabilities are provided for all students with a qualified
disability under the Americans with Disabilities Act (ADA & ADAAA) and Section 504 of the
Rehabilitation Act who request and are eligible for accommodations. The Office of Student
Disability Services (SDS) is the UMBC department designated to coordinate accommodations
that would create equal access for students when barriers to participation exist in University
courses, programs, or activities.

If you have a documented disability and need to request academic accommodations in your
courses, please refer to the SDS website at sds.umbc.edu for registration information and office
procedures.

12
SDS email: disAbility@umbc.edu
SDS phone: (410) 455-2459

If you will be using SDS approved accommodations in this class, please contact me (instructor)
to discuss implementation of the accommodations. During remote instruction requirements due
to COVID, communication and flexibility will be essential for success.

Sexual Assault, Sexual Harassment, and Gender Based Violence and Discrimination

UMBC’s Policy on Sexual Misconduct, Sexual Harassment and Gender Discrimination and
Federal Title IX law prohibit discrimination and harassment on the basis of sex in University
programs and activities. Any student who is impacted by sexual harassment, sexual assault,
domestic violence, dating violence, stalking, sexual exploitation, gender discrimination,
pregnancy discrimination, gender-based harassment or retaliation should contact the University’s
Title IX Coordinator to make a report and/or access support and resources:

Mikhel A. Kushner, Title IX Coordinator (she/her/hers)

410-455-1250 (direct line), kushner@umbc.edu

You can access support and resources even if you do not want to take any further action. You
will not be forced to file a formal complaint or police report. Please be aware that the University
may take action on its own if essential to protect the safety of the community.

If you are interested in or thinking about making a report, please see the Online Reporting Form.
Please note that, while University options to respond may be limited, there is an anonymous
reporting option via the online form and every effort will be made to address concerns reported
anonymously.

Notice that Faculty are Responsible Employees with Mandatory Reporting Obligations:

All faculty members are considered Responsible Employees, per UMBC’s Policy on Sexual
Misconduct, Sexual Harassment, and Gender Discrimination. Faculty are therefore required to
report possible violations of the Policy to the Title IX Coordinator, even if a student discloses
something they experienced before attending UMBC.

While faculty members want you to be able to share information related to your life experiences
through discussion and written work, students should understand that faculty are required to
report Sexual Misconduct to the Title IX Coordinator so that the University can inform students
of their rights, resources and support.

13
If you need to speak with someone in confidence, who does not have an obligation to report to
the Title IX Coordinator, UMBC has a number of Confidential Resources available to support
you:

 The Counseling Center: 410-455-2472 / After-Hours 410-455-3230

 University Health Services: 410-455-2542

 Pastoral Counseling via Interfaith Center: 410-455-3657; interfaith@umbc.edu

Other Resources:

 Women’s Center (for students of all genders): 410-455-2714; womenscenter@umbc.edu.

 Shady Grove Student Resources, Maryland Resources, National Resources.

Child Abuse and Neglect:

Please note that Maryland law and UMBC policy require that I report all disclosures or
suspicions of child abuse or neglect to the Department of Social Services and/or the police.

Pregnancy

UMBC’s Policy on Sexual Misconduct, Sexual Harassment and Gender Discrimination

expressly prohibits all forms of Discrimination and Harassment on the basis of sex, including
pregnancy. Resources for pregnant students are available through the University’s Office of
Equity and Inclusion. Pregnant and parenting students are encouraged to contact the Title IX
Coordinator to discuss plans and assure ongoing access to their academic program with respect
to a leave of absence or return following leave related to pregnancy, delivery, or the early
months of parenting.

In addition, students who are pregnant may be entitled to accommodations under the ADA
through the Student Disability Service Office, and/or under Title IX through the Office of
Equity and Inclusion.

Religious Observances & Accommodations

UMBC Policy provides that students should not be penalized because of observances of their
religious beliefs, students shall be given an opportunity, whenever feasible, to make up within a
reasonable time any academic assignment that is missed due to individual participation in
religious observances. It is the responsibility of the student to inform the instructor of any

14
intended absences for religious observances in advance, and as early as possible. For questions
or guidance or to request an accommodation, please contact the Office of Equity and Inclusion at
oei@umbc.edu.

Hate, Bias, Discrimination and Harassment

UMBC values safety, cultural and ethnic diversity, social responsibility, lifelong learning,
equity, and civic engagement.

Consistent with these principles, UMBC Policy prohibits discrimination and harassment in its
educational programs and activities or with respect to employment terms and conditions based
on race, creed, color, religion, sex, gender, pregnancy, ancestry, age, gender identity or
expression, national origin, veterans status, marital status, sexual orientation, physical or mental
disability, or genetic information.

Students (and faculty and staff) who experience discrimination, harassment, hate or bias or who
have such matters reported to them should use the online reporting form to report discrimination,
hate or bias incidents; reporting may be anonymous.

15