COURSE TITLE: Health Care for the Indigent – Health Care for the Underserved

DEPARTMENT: Health Policy and Management 

COURSE NUMBER: HPM 565     SECTION: 000     SEMESTER: Fall 2020

CREDIT HOURS: 2

INSTRUCTOR NAME: Lawrence Sanders Jr., MD, MBA, Adjunct Assistant Professor INSTRUCTOR CONTACT INFORMATION EMAIL: lsanders1@gmh.edu PHONE: 404-202-4178 SCHOOL ADDRESS OR MAILBOX LOCATION: 1518 Clifton Road, Atlanta, GA 30322 OFFICE HOURS: By Appointment – please e-mail or call instructor to schedule appointment TA NAME: Gabrielle Metoyer TA CONTACT INFORMATION EMAIL: gabrielle.metoyer@emory.edu PHONE: 281-757-0995, please text or email before you call

BRIEF COURSE DESCRIPTION This course explores populations of Americans underserved by the health care system.  Topics cover the impact of living without insurance or enough insurance, services aimed to address the needs of underserved populations, health disparities, and health system change.  The course intends to equip students to understand both existing approaches and the policy development necessary to shape future directions.

COMPETENCIES MPH-Policy program-related competencies Primary degree program competencies Prepare health policy briefings suitable for the range of policy stakeholders involved with the formulation and implementation of a health policy under consideration by decision-makers Design and advocacy strategy for the development and implementation of a health policy MPH-Health Management program-related competencies Primary degree program competencies Assume supervisory-level general-management responsibilities in a health services delivery organization Execute both an operations management and a strategic management analysis in the role of a health services consultant MSPH-Health Policy and Health Services Research program-related competencies  Primary degree program competencies Function as a team collaborator in the development and/or execution of a health services research investigation PhD-Health Services Research and Health Policy program-related competencies Primary degree program competencies Conduct a health services or health policy research investigation suitable for peer-reviewed publication as an independent researcher Function as an interdisciplinary team collaborator in the design and conducting of a health services or health policy research investigation

 

LEARNING OBJECTIVES The major goal of HPM 565 is to foster the development of a framework to understand the health service needs of people underserved by the existing US health service delivery systems and the challenges of defining and addressing the needs of these population groups. Upon completion of the course students will be able to: Characterize population groups suffering disparities in health status and facing greater challenges and access barriers to needed health services Discuss major components and implementation of the 2010 Patient Protection and Affordable Care Act with a focus on underserved populations Recognize challenges faced by the health care safety net Understand the gaps in the current system of insurance coverage and the roles of Medicaid and Medicare and the impact of economic challenge and reform Examine influences of race and other characteristics on disparities in health status and access to health services Forecast the evolving role of public health within an era of rapid change Align proposed health care reform initiatives with health system changes necessary to assure access to affordable high-quality health services for people underserved by today’s health service delivery system
EVALUATION Grading             Class Participation                                30%             Group Projects                                      35%             Final Paper                                            35%
ACADEMIC HONOR CODE The RSPH requires that all material submitted by a student in fulfilling his or her academic course of study must be the original work of the student.

 

The Course

For some time now, rapid and accelerating structural change -- driven by demands for improved efficiency, higher quality, equitable access, and lower costs -- characterizes the US health services delivery system.  For at least the last six months, the world -- including the United States --  faces a new infection – COVID-19 – adding stress to an already challenged health care system.   COVID-19 serves to make already well documented weak spots more transparent and highlights unrecognized health care challenges for both people historically well served by our health care system and vulnerable underserved populations. 

 

In March 2010, Congress passed the Patient Protection and Affordable Care Act and put in place a framework for the transformation of health service delivery with the aims of better health, better health care, and reduced spending. This legislation outlines steps to reform current systems of service delivery and to address the needs of many people living in neighborhoods and communities in the United States.  The objective is to achieve better health, better health care, and lower costs for all Americans.  The course explores well-documented inefficiencies and inequalities of health and health service delivery and stimulates dialogue related to the potential of the evolving systems to either resolve or compound existing inefficiencies with a specific focus on underserved populations.   

 

The content of this course focuses on two major areas.  The first area seeks to understand the groups of Americans facing both greater challenges related to access to needed health services and growing disparities in health status.  The second area explores the delivery of services to these specific population groups.  Students examine questions related to the delivery of services for people traditionally underserved by health systems and explore potential strategies to address the health and health service needs of the underserved. 

 

Readings

Readings from the current literature are assigned for each lecture.  Reading provides background and current information for class discussion.  The readings in the assignments folder and found here in the syllabus serves as the focus for class discussions.  Additional reading may be posted for the class. 

Readings provide the background and the key discussion facts for each topic.  Also, students are encouraged to keep abreast of news reports related to class material.

 

Ground Rules

1. Attendance at all classes is expected.
2. If a student needs to talk with the instructor outside of class, the student should send e-mail or call to schedule an appropriate meeting and time
3. Group projects are expected to reflect the work of the group and not the work of individual students aggregated for presentation

 

Class Schedule

August 17

Structure, Learning Framework and Expectations

• Context
• Syllabus overview
• Small groups and projects
• Grading
• Other concerns

Context: Consider the conceptual meaning of health care for the indigent and health care for the underserved. 

1. Are the two concepts equivalents?
2. What thoughts are provoked by both sets of words?
3. Why explore underserved populations?
4. What is the relationship to Public Health?

 

August 24

Life Expectancy in the USA

Who are the underserved populations?

Who remains without health insurance?

 

Learning Objectives

1. Recognize life expectancy as a measure of health status for populations
2. Appreciate the trends in life expectancy in the USA
3. Describe the aggregate population of people in the USA living without health insurance and without enough health insurance 

Readings

• Key Facts about the Uninsured Populations Kaiser Family Foundation www.kff.org.  December, 2019
• Garfield R., Rae, M. et. al.  Double Jeopardy: Low wage workers at risk for health and financial implication of COVId-19.  www.kkf.org April 29, 2020
• Tolbert J., What issues will uninsured people face with testing and treatment for COViD-19? www.kff.org March 16, 2020
• The Uninsured.  A primer - Key facts about health insurance and the uninsured in the era of health care reform Kaiser Family Foundation www.kff.org. January 2019
• Squires and Blumenthal.  Mortality trends among working age whites – the untold story.  Issue Brief Commonwealth Fund www.commonwealthfund.org January 2016

Other references

• Bound J, Germimus T, et. al.  Measuring recent apparent declines in longevity – the role of increasing educational attainment.  Health Affairs 34 (12) 2015 2167-2173
• Case A, Deaton A.  Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21^st century.  Proceedings of the National Academy of Science, September 2015
• Squires and Anderson US Health Care from a global perspective.  Issues in international health policy.  The Commonwealth Fund www.commonwealth.org October 2015
• Harper, Sam, et al. Trends in the black-white life expectancy gap among US States, 1990-2009.  Health Affairs August 2014
• Lewis C, Abrams K, and Seervai S. Listening to low-income patients  Obstacles to the care we need, when we need it Commonwealth Fund www.commonwealthfund.org December 2017
• Altman, Drew.  It is not just the uninsured – it’s the cost of care.  Axios www.axios.com August 2018
• Lewis Decker and Lipton Most new insured in 2014 were long term uninsured   Health Affairs 36, 2017: 16-20
• Hinton and Artiga Characteristics of Remaining Uninsured Men and Potential Strategies to Reach and Enroll them in Health Coverage Kaiser Family Foundation www.kff.org April 2016

 

August 31

Health Care Reform – Focus on the Underserved

Where are we 10 years later?

 

Learning Objectives

 Outline key components of health care reform legislation 

1. Describe progress and challenges to implementation
2. Focus on initiatives to expand insurance coverage and to improve health and health care

Readings

• Summary of the affordable care act.  Kaiser Family Foundation April 2013
• Collins S., Fowler E., Repealing the affordable care act just when people need it most.  The Commonwealth Fund www.commonwealthfund.org July 14. 2020
• Obama, Barack.  United States Health Care Reform—Progress to date and next steps.  JAMA 2016;316 (5) 525-532

Other readings

• Lui J and Elbner C.  Expanding enrollment without the individual mandate: options to bring more people into the individual market Commonwealth Fund  www.commonwealthfund.org  August 2018
• Sobel L, Rosenzweig C and Salganicoft A.  Proposed changes to Title X: implications for women and family planning providers  Kaiser Family Foundation www.kff.org June 2018
• Kaiser Family Foundation Poll: Large Majority of the Public, Including Half of Republicans and Trump Supporters, Say the Administration Should Try to Make the Affordable Care Act Work Press Release www.kff.org August 2017
• Altman, Drew.  The ACA stability “crisis” in perspective.  Axios  www.kff.org August 2017
• Jost TS A midsummer night’s strange reality.  Health Affairs 36, 2017 1528-1529

 

September 7 No Class – Labor Day

 

September 14

Disparities – What determinants contribute to disparities?

 

Learning Objectives

1. Identify health service delivery and health policy interventions linked to eliminating health disparities
2. Reflect on the complexity of health determinants and the persistence of health disparities by race and ethnicity
3. Differentiate the role of physicians and health service delivery and broad public policy decision-makers in eliminating health disparities
4. Recognize the value of a systems approach to understanding and eliminating disparities

Readings

• Wilkinson Richard and Picket Kate. Greater equity – the key to better health and higher scores.  American Educator Spring 2011
• LaVeist T ., Pollack K, Thorpe, R et.al.  Place, not race: disparities dissipate in Southwest Baltimore when black and whites live under similar conditions Health Affairs volume 30:10 October 2011
• Woolf, S.,Braveman P, Where health disparities begin: the role of social and economic determinants – and why current policies may make matters worse.  Health Affairs Volume 30:10 October 2011
• Kawachi I, Daniel N, Robinson DE.  Health disparities by race and class: why both matter. Health Affairs Volume 24 Number 2 (2005): 343-352.
• Probst J, Bellinge  JD, Walsemann KM, et.al.  Higher risk of death in rural blacks and whites than urbanites is related to lower incomes, education and health coverage.  Health Affairs Volume 30:10 October 2011
• Olshansky SJ et al.  Difference in life expectancy due to race and educational difference are widening, and many may not catch up.  Health Affairs August 2012

 

September 21

COVID-19 – What’s next?

 

Readings

• Tikkanen R., Wharton G., et.al. The 2020 international profiles of health care systems; a useful resource for interpreting country responses to the COVID-19 pandemic The Commonwealth Fund www.commonwealth.org June 2020
• Rae M, Neuman T., et. al., Millions of seniors live in households with school-age children www.kff.org July 16, 2020

 

September 28 NO CLASS

 

October 5

Public Insurance -- Medicaid and Medicaid Expansion -- The Underserved and Insurance – Focus on Medicaid

1. Medicaid
2. State Children’s Health Insurance Program
3. Medicare
4. Health insurance exchanges
5. Self-Pay

 

Learning Objectives

1. Recognize the significant role Medicaid plays in the US health care service delivery system
2. Predict the future role of Medicaid in US health care
3. Outline the mechanisms used to finance Medicaid

Readings

• Issue Brief: 10 things about Medicaid – setting the facts straight www.kff.org April 2018
• Hall C., Artiga S., et.al. Food insecurity and health: Addressing food needs for Medical enrollees as part of COVID-19 response efforts Issue Brief www.kff.org August 14, 2020
• Rudowitz R., Garfield R., et.al. Understanding the intersection of Medicaid, work and COVID-19 Issue Brief  www.kff.org  June 12, 2020
• Collins S., Gunja M., et.al.  An early look at the potential implications of the COVID-19 pandemic for health insurance coverage. Health Care Poll - May June 2020.  The Commonwealth Fund www.commomwealth.org June 2020
• Garfield R., Rudowitz R., et. al.  How many uninsured adults could be reached if all States expanded Medicaid?  Kff.org June 25, 2020

Medicaid’s Role

• Medicaid’s role in trauma care Issue Brief Kaiser Family Foundation www.kff.org August 2017
• Medicaid’s role in financing behavioral health services for low income individuals.  Issue Brief Kaiser Family Foundation www.kff.org June 2017
• Medicaid’s role in nursing home care.  Issue  Brief Kaiser Family Foundation www.kff.org June 2017
• Medicaid’s role in rural America Issue Brief Kaiser Family Foundation www.kff.org April 2017 
• Medicaid Pocket Primer.  Kaiser Family Foundation www.kff.org

Historical Perspectives

• Bachrach D, Guyer J et al.  Enabling sustainable investments in social interventions: Medicaid managed care rate setting tools Commonwealth Fund  www.commonwealthfund.org January 2018
• Medicaid at 50  Medicaid and the uninsured Kaiser Family Foundation 2015
• Medicare – Facts on Medicare spending and financing.  Issue Brief Kaiser Family Foundation www.kff.org July 2017
• Davis, Schoen, Bandeali.  Medicare 50 years of ensuring coverage and care The Commonwealth Fund April 2015

 

October 12 

Public Delivery Systems – Safety Net Roles -- Public Hospitals, Community Health Centers

 

Learning Objectives

1. Define the health care safety net and the role of public hospitals
2. Appreciate the historical role of public hospitals
3. Project the future of public hospitals

Readings

• Corallo B., Tolbert J. Impact of Coronavirus on Community Health Centers www.kff.org  May 2020
• Community Health Centers – Recent Growth and the role of the ACA Issue Brief Issue Brief Kaiser Family Foundation www.kff.org January 2017
• Essential data Our hospitals, Our patients America’s Essential hospitals www.essentialhospitals.org June 2017
• Delivery innovations Health Affairs 36 2017 392-393
• Dianove D, Garthwaite C et. al.  Uncompensated care decreases at hospitals in Medicaid expansion states but not in hospitals in non-expansion states Health Affairs Volume 35(8)  2016 1471-1479

 

October 19

Medicaid Expansion

Case Study – Medicaid Expansion

 

Learning Objectives

1. Recognize the vast connections to Medicaid
2. Distinguish the social and community benefit of Medicaid expansion 

Readings

• How Western Kentucky leverage Medicaid expansion to increase access to health care  Commonwealth Fund www.commonwealthfund.org July 2017
• Altman, Drew   The big warning in Kentucky Medicaid decision Axios www.axios.com  July 2018

 

October 26

Quality – What does it mean?  Focus on Underserved Populations

 

Learning Objectives

1. Appreciate the complexity of defining quality
2. Understand the trade-offs necessity to achieve the highest quality for all people
3. Recognize potential consequences of multiple health service delivery tiers

Readings

• Pauly, Mark, The trade-off among quality, quantity, and cost; how to make it – if we must. Health Affairs, Volume 30, Number 4 (2011) 574-580.
• Weinick RM and Hasnain-Wynia R.  Quality improvement efforts under health reform: how to ensure that they help reduce disparities – not increase them.  Health Affairs Volume 30:10 October 2011
• 2018 National Healthcare Quality and Disparities Report AHRQ
• Beal, Anne. High quality health care; the essential route to eliminating disparities and achieving health equity.  Health Affairs Volume 30:10 October 2011
• Jha AK, Orav EJ, and Epstein AM.  Low-quality, high cost hospitals, mainly in the South, care for sharply higher shares of elderly Black, Hispanic and Medicaid patients.  Health Affairs volume 30:10 October 2011
• Lurie N, Jung M, Lavizzo-Mouray R. et al., Disparities and quality improvement: federal policy levers. Health Affairs Volume 24, Number 2 (2005): 354-364.

 

November 2

Class Presentations

Case Study – Philadelphia

• Building Health and Resiliency: Philadelphia’s 11^th Street family health services 
• Case Study  Primary Care for low income populations Commonwealth Fund  www.commonwealth.org April 2019

Case Study -- South Carolina

• Building partnerships to improve health in the rural South.  CareSouth Carolina   What is the best way for a community health center to have impact an impact beyond its walls? 
• Case Study—Primary care for low-income populations. Commonwealth Fund www.commonwealth.org February 2020

 

November 9

Class Presentations

Case Study – Akron, Ohio

• Health care improvement in Akron, Ohio: Moving from collaboration to coordination
• Case Study The Commonwealth Fund.  www.commonwealth.org August 2017  

 

November 16

Social Justice -- Public Health as a Critical Factor

 

Learning Objectives

1. Recognize the historical links between social justice and public health
2. Use a historical context to explore the future role of public health

Readings

• Williams DR, McClellan MB, Rivlin AM. Beyond the affordable care act Health Affairs Volume 29, Number 8 (2010): 1481-1488
• Gostin L, and Powers M. What does social justice require for the public’s health?  Public Health ethics and policy imperatives.  Health Affairs Volume 25 Number 4 July/August 2006.
• Honore PA, Wright D, Berwick DM, et al. Creating a framework for getting quality into the public health system. Health Affairs volume 30 Number 4 (2011): 737-745
• Beitsch L, Brooks R et al.  Public Health at Center Stage: New Role, Old Props.  Health Affairs Volume 25 Number 4 July/August 2006
• Luck J, Chang C et al. Using Local Health Information to Promote Public Health.  Health Affairs Volume 23 Number 2 July/August 2006

 

December 7

Final paper