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Public Health Law and Policy, Fall 2016 Harvard Law School

Clinical Professor Robert Greenwald Tuesdays 5:00 – 7:00pm

WCC 3012

Instructor: Administrative Director: Professor Greenwald, rgreenwa@law.harvard.edu Laura Johnston, ljohnston@law.harvard.edu Faculty Assistant to Professor Greenwald: Ebony Griffin, egriffin@law.harvard.edu Course Website: Available to students on Canvas at canvas.harvard.edu Course Description: This seminar will provide an overview of the historical law and policy decisions that have shaped the U.S. health care system and are informing current debates about health reform. Students will learn about the structure and functioning of the U.S. health care system, with a focus on how this system is working (or not working) for vulnerable populations (e.g., low-income people living with HIV and AIDS, hepatitis, mental illness, and other chronic health conditions). Incorporating varying perspectives, the seminar will discuss and analyze federal and state policy options that the nation has going forward to address the current public health and access to care crisis that is in large part a direct outgrowth of millions of Americans being without health insurance. The seminar will encourage discourse, dialogue, and debate from all perspectives about U.S. health and public health law and policy choices. In this seminar we will analyze and discuss key elements of the current U.S. health care system as well as major federal and state law and policy initiatives, including the national health care reform law – the Patient Protection and Affordable Care Act (ACA) – with a focus on how these initiatives impact access to care for vulnerable populations. Throughout the semester students will have the opportunity to identify or propose innovative solutions to ACA implementation challenges or public health problems. This seminar will begin with an overview and comparison of the health systems currently in place in other democratic countries, to put the U.S. health system and reforms under the Affordable Care Act into context. Next, we will discuss the origins of the U.S. health system and key policy decisions over the past century that have shaped the current patchwork of public and private insurance coverage options in this country. After providing this international and historical context, we will move to a detailed analysis of the key elements of current U.S. health and public health systems. We will look at components of federal and state approaches to reforms, looking at health and public health initiatives aimed at particular areas of concern or populations. Finally, we will look at what forces are at play that favor the health policy status quo in this country and then discuss the many avenues that health policy solutions focusing on increasing access to health care and addressing public health concerns can take. Course Requirements: The seminar is open to students interested in health and public health law and policy and their implications on access to care for vulnerable populations. No background or prerequisites are required. The reading materials for the course will be provided in a course reader and on the course website, and will include various book chapters, cases, news reports, and scholarly articles that present diverse viewpoints on the topics presented. The course is intended to spark debate between different sides of these often controversial issues. This seminar has a no laptop policy. In addition to discussion of the reading for each course theme, requirements include: submitting 4 discussion posts during the course of the semester; drafting a few short written assignments and a four-to five page policy paper; and preparing for and participating in in-class role playing activities.

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Readings: The syllabus and course readings are available online at the Canvas site. Readings are also provided in the course reader, which is available at the Harvard Law School Copy Center. Students are responsible for all readings every week, not only those for which they write responses. Reading the course materials in advance of class is important so that we can have more interesting discussions that build off the content rather than spending the time to reiterate what was read. Discussion posts (choose 4 weeks): To help you think actively about the readings, we ask that you post on the course website, in the “Discussions” page, 4 times during the 12 weeks of the course. Discussion posts should be approximately 350 words and should respond to one of the readings or a theme in the readings for the week. Discussion posts should reflect your reaction to an issue rather than merely summarizing facts – they are meant to encourage critical thinking and spark discussion. There are a few rules for the discussion posts: • For days when there is an in-class debate or written assignment due, please do not write a “response” on the same topic as the written or in-class assignment. Note that you can still post the same week, but choose a different topic from that day’s reading. • Posts are due online by midnight on the Sunday before class. • NOTE: the discussions are a great way for everyone to see the responses of classmates and prepare for class. You can respond to other classmates’ posts, but also be prepared for us to discuss the posts in class. Written Assignments: Students will be responsible for short (1-2 page) written assignments throughout the course of the semester. Assignments are described in detail in the syllabus each week. In addition, a short summary of all of the written assignments is included in this syllabus. Unless otherwise noted, all written assignments are due online in the Assignments link by midnight on the Sunday before class. If you have any problems submitting an assignment please contact Ebony Griffin at egriffin@law.harvard.edu. Policy Paper: Students will be responsible for preparing one policy paper (4-5 pages, single spaced) and for presenting the proposed strategy outlined in the policy paper to the class in either Class 11 or 12. Each student will complete one of the two possible policy papers: • Class 11: policy brief on strategies to address an ongoing barrier to access to health care • Class 12: policy brief on strategies to address a public health challenge Students can sign up for the Class 11 or 12 policy paper assignment, using the sign in sheet that is provided the first night of class and on the Canvas course site. (We will do our best to accommodate student interest but will make assignments as necessary). Students will submit a policy paper outline to the Assignments link on 10/23 (before Class 7) in order to receive feedback from the instructor. For those students presenting their policy papers in Class 11 the papers are due online in the Assignments link by midnight on 11/17. For those presenting in Class 12 the papers are due by midnight on 11/24. This will give us all enough time to read the papers prior to the class discussions. In-class activities: In addition to written assignments, in several classes we will conduct in-class activities, including summits or debates. In some of the activities the entire class will participate, in others some students will be participants and others will be questioners or observers. Each student will be assigned to one activity as a role in the summit or debate and to one activity as a questioner. At the end of Class 1, we will distribute a sign-up sheet for students to sign up for participation in in-class activities. We will do our best to accommodate student requests. There is no final paper or final exam.

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Grading Policy: Students will be evaluated as follows: • Participation in in-class activities, presenting policy paper and class discussions: 50% • Discussion posts, written assignments and policy paper: 50% Please DO NOT bring laptops to class

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Class Schedule Class #1 (9/6) Overview of Western Health Systems

Class #2 (9/13) Overview of the ACA and Constitutional Challenges to the ACA

Class # 3 (9/20) History and Politics of the U.S. Health Care System

Class #4 (9/27) The Future of Private Health Insurance and Public Coverage Programs

Class # 5 (10/4) Discretionary Health Programs

*** There is no class on 10/11 *** Class #6 (10/18) Public Health, Infectious Disease Epidemics, and Disease Control: Zika Outbreak as a Case Study

Class #7 (10/25) Public Health: Prevention and Addressing Health Disparities: Obesity as a Case Study Class #8 (11/1) Science versus Politics and the Pursuit of Public Health Class #9 (11/8) Public Health and the Courts Class #10 (11/15) Economics of Health Care - Drivers of Spending and Policy Levers: Finance, Payment and Delivery Reforms Class #11 (11/22) Innovative Solutions to Ongoing Barriers to Access to Care Class #12 (11/29) Innovative Solutions to Public Health Challenges

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Fall 2016 Written Assignments Overview *Students are expected to complete all readings for each class. Class 1: Questionnaire: Sick Around the World All students view the Sick Around the World video and complete the Questionnaire. Due Sunday, September 4th. Class 2: Summit: Recent Challenges to the Affordable Care Act Each student assigned to participate in the ACA challenges summit submits a brief outline of their assigned position in the case. Students assigned as questioners pose questions to the summit participants prior to the open class discussion. All students submit a brief description on how he or she thinks the Court should address the issues discussed. Due Sunday, September 11th. Class 3: Presentations: Health Reform Efforts of the 20th Century Each student assigned a health reform platform (Truman, Nixon or Clinton) submits an outline and presents on their assigned health reform platform. All other students submit a one page outline of the interests of their assigned stakeholder group historically involved with health reform efforts in the U.S. All students will also include a brief discussion of which approach you think the U.S. should have taken to health reform and why. Due Sunday, September 18th. Class 4: Governors’ Roundtable: State Approaches to Medicaid Reform Students are assigned to play the role of either a state governor or a staff member of the National Governors Association (NGA) Center for Best Practices Health Division (who will be questioning a governor) for an in-class roundtable discussion on state approaches to Medicaid reform. Students submit a brief outline (1-2 pages, bullet points are fine) of either your governor’s position or questions designed to examine the rationale and likely efficacy of your assigned governor’s approach. Students may be assigned in teams of two; in that case students should collaborate with their teammates and submit only one outline or set of questions per team. Students assigned to be governors should be prepared to discuss/defend that governor’s position in class. Students assigned to be NGA staff should be prepared to ask their questions at the in-class mock roundtable. Due Sunday, September 25th. Class 5: Readings only Class 6: Summit: Health Policy Convening on Zika Outbreak All students will be assigned a role in the Convening and will write a 1-2 page policy paper responding to the assignment questions. All students also submit a few paragraphs explaining what he or she thinks personally is the right course of action for addressing the outbreak. Due Sunday, October 16th. Students assigned to play Thomas Frieden will also complete a 1-2 page outline to guide their summit discussion. These outlines should note what challenges face the summit participants as they attempt to address the zika epidemic as well as outline potential next steps. Due Sunday, October 16th.

Class 7: Debate: Limiting the Use of SNAP Benefits Students assigned as debaters submit an outline. Students assigned as questioners pose questions to the debaters prior to the open class discussion. All students submit a few paragraphs explaining what he or she thinks personally is the right course of action in the SNAP debate. Due Sunday, October 23rd . * Students should also submit their Class 11 or 12 policy paper outline by Sunday, October 23rd . Class 8: Focused Discussions: Science versus Politics and the Pursuit of Public Health

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There is no written assignment for this class, although an outline may be helpful to your participation in the focused discussions. Class 9: Analysis: Public Health and the Courts All students write a 1-2 page analysis of one of the judicial decisions included in the readings, either in support or as a criticism. Describe how the decision promotes or harms public health. Due Sunday, November 6th. Class 10: Economics of Health Care Readings Only Class 11: Policy Paper: Innovative Solutions to Ongoing Barriers to Access to Care Half of the class will submit a policy paper aimed at addressing an ongoing barrier to access to health care. Note that the policy papers are due on Thursday, November 17th. The papers will then be distributed to all members of the class to read them prior to class on November 22nd. Class 12: Policy Paper: Innovative Solutions to Public Health Challenges Half of the class will submit a policy paper aimed at addressing an ongoing public health challenge. Note that the policy papers are due on Thursday, November 24th. The papers will then be distributed to all members of the class to read them prior to class on November 29th.

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CLASS 1: OVERVIEW OF WESTERN HEALTH SYSTEMS Objectives 1. To review the syllabus and provide an overview of what’s expected of students in the seminar. 2. To explore how other democracies deliver health care and to discuss what the U.S. might learn from their successes and failures. Assignments Review the Syllabus. View PBS Frontline special “Sick Around the World” (approximate run time 55 minutes). The film is available online at http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/main.html Complete the Sick Around the World Questionnaire. Be prepared to discuss your responses in class. Deadline: Submit your assignment to the Assignments link on the course website by midnight, Sunday, September 4th. Reading Assignments (Tab 1): • Cutler, D. M., “Equality, Efficiency, and Market Fundamentals: The Dynamics of International Medical Care Reform,” Journal of Economic Literature, 40, no.3 (September 2002), 881-906. • Mossialos, E., et. al., “2015 International Profiles of Health Care Systems,” The Commonwealth Fund (January 2016), England: 49-58, Germany: 69-76, Japan: 107-114, Switzerland: 161-170. • Cheng, T-M, “Reflections on the 20th Anniversary of Taiwan’s Single-Payer National Health Insurance System,” Health Affairs, 34, no. 3 (March 2015). • Davis, K., et. al., “2014 Update Mirror, Mirror on the Wall: How the U.S. Health Care System Compares Internationally,” The Commonwealth Fund (June 2014). Pages 7-10 only. • Schoen, C., et.al., “New 2011 Survey of Patients with Complex Care Needs in 11 Countries Finds That Care Is Often Poorly Coordinated,” Health Affairs, 30, no. 12 (December 2011). In-Class Format: Lecture: (30 minutes) Professor Greenwald will provide an introduction to the seminar. Discussion: (90 minutes) During this class, we will discuss our reactions to “Sick Around the World” and the other assigned readings, considering the strengths and challenges associated with each country’s approach to addressing the provision of high-quality health care to its residents.

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CLASS 2: OVERVIEW OF THE ACA AND CONSTITUTIONAL CHALLENGES TO THE ACA Objectives 1. To describe the Patient Protection and Affordable Care Act (ACA) and to help students understand opportunities provided by the ACA to remove barriers to care for poor and low-income people and to provide integrated and coordinated care systems for individuals living with chronic medical conditions. 2. To provide an overview of recent legal challenges levied in opposition to the ACA. Assignments Reading Assignments (Tab 2): • SKIM: Kaiser Family Foundation, “Summary of the Affordable Care Act,” April 23, 2013. • Case Readings: In an effort to reduce the required reading, for each of the case reading assignments below, there are certain sections that demand less attention for purposes of our class discussion, and so students can skip or skim sections as noted. (All cases are available in course packet and on course website.)

o King v. Burwell, 576 U.S. __ (2015). o National Federation of Independent Business Owners v. Sebelius, 576 U.S. __ (2012). READ: Intro (1-6); Individual Mandate: J. Roberts Opinion pp 16-44; Ginsburg dissent pp 2-37; Scalia Dissent: 1-27. Medicaid Expansion: J. Roberts Opinion pp 45-59; Ginsburg dissent pp. 38-60; Scalia Dissent pp. 1-3; 28-48. SKIM: Rest of the majority and dissents.

Class Preparation Work: For the second part of class we will have two “mock” summits – one of the justices who issued written opinions in King and the other of the justices who issued written opinions in National Federation of Independent Business (NFIB). For the King summit, one student will present Justice Roberts’s opinion of the Court and one student will present Justice Scalia’s dissent. We only have about 15 minutes for this portion of the summit, so focus on the main arguments and a succinct presentation. All students should be generally familiar with all of the arguments raised in the case, with students participating as the Justices in the summit particularly well-versed in their assigned position and able to pose questions or challenges to students representing the opposing position. After the presentations, questioners (and, with time permitting, other students) will have the opportunity to ask questions of the “Justices.” We will then break out of role and discuss how we think the case should have been decided. We will conduct a similar summit for the NFIB case. One student will present Justice Roberts’s opinion of the Court and one student will present Justice Scalia’s dissent, focusing on (1) the individual mandate and (2) Medicaid expansion. Again, we only have about 15 minutes for this portion of the summit, so focus on the main arguments and a succinct presentation. All students should be generally familiar with all of the arguments raised in the assigned portions of the cases, with students participating in the summit particularly well-versed in their assigned position and able to pose questions or challenge students representing the opposing position. After the presentations, questioners (and, with time permitting, other students) will have the opportunity to ask questions of the presenters We will then break out of role and discuss how we think the case should have been decided.

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Written Work: Students participating as Justices should prepare an outline (not longer than a page or two) of the merits of your assigned position as well as the key challenges to the opposing position you think demand attention. Also, include a paragraph or two at the end of the assignment explaining how you think the Court should decide the issue and why. Questioners should prepare at least one question for all the “Justices.” You do not need to submit your questions to the Assignments link but are welcome to read the debate outlines submitted by debate participants prior to class to help you prepare your questions. All students submit a written paragraph or two explaining how you think the Court should have decided King and NFIB. Deadline: The deadline for submission of your written assignment to the Assignments link is midnight, Sunday, September 11th. In-Class Format: ACA Overview (40 minutes) -- Instructors will provide an introduction to the ACA, including an overview of how the ACA has expanded access to care, the ongoing barriers to access, how the health care landscape has changed, and implementation successes and challenges. Challenges to the ACA (80 minutes) – We will conduct summits on the King and NFIB cases, with students assigned as the leading Justices involved in the cases, briefly presenting the leading arguments for the position assigned to them. These presentations will be followed by a brief period where opposing parties and other students may pose questions/challenges. Each summit will conclude with all students breaking out of their assigned roles and discussing their personal views of the case decisions.

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CLASS 3: HISTORY AND POLITICS OF THE U.S. HEALTH CARE SYSTEM Objectives 1. To provide an overview of the history and development of the private and employer-based health insurance systems in the U.S. as context and framework for understanding health reform efforts. 2. To describe and analyze the major U.S. health reform movements in the 20th century, including the contemporary political, social, and economic forces affecting proposed plans to reform health care organization, financing, and delivery systems. 3. To understand the successes and failures of different health reform efforts, the different directions that health reform could have taken, and to decide which path would have been best from the student’s own perspective. Assignments Reading Assignments (Tab 3): • The Henry J. Kaiser Family Foundation, “National Health Insurance: A Brief History of Reform Efforts in the U.S.,” Mar. 2009. • Blumenthal, D., “Employer-Sponsored Health Insurance in the United States – Origins and Implications,” New England Journal of Medicine 355(1), 2006: 82-88. • Morone, J., “Presidents And Health Reform: From Franklin D. Roosevelt To Barack Obama,” Health Affairs 2010;29(6):1096-100. • Schremmer, R., et. al., “Harry Truman and Health Care Reform: The Debate Started Here,” Pediatrics, February 2011. • Kaiser Health News, “Nixon’s Plan for Health Reform, In His Own Words,” September 2009. • Starr, P., “The Hillarycare Mythology,” The American Prospect, October 2007. • Miller, T., “Health Reform: Only A Cease-Fire In A Political Hundred Years’ War,” Health Affairs 2010;29(6):1101-5. Optional readings for written work assignment: The following sources may provide additional helpful information as you prepare for your assigned roles. You are also welcome to use any other outside sources for this assignment. (All of the optional readings are available on the course website in the Files link.) • Paul Starr. 2011. Remedy and Reaction: The Peculiar American Struggle Over Health Care Reform. New Haven, CT: Yale University Press. (chapter 1, pp. 35-50, chapter 2, pp. 51-63, chapters 3 and 4) • Stuart Altman and David Shactman. 2011. Power, Politics, and Universal Health Care: The Inside Story of a Century-Long Battle. Amherst, NY: Prometheus Press. (chapters 1 and 2) • The Center for Public Integrity, “Well Healed: Inside Lobbying for Health Care Reform,” (1994) • Terris, M., “Crisis and Change in America’s Health System,” American Journal of Public Health, 1973. • Skocpol, T., “The Rise and Resounding Demise of the Clinton Plan,” Health Affairs, 1995.

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• Brodie, M., et. al., “Liking The Pieces, Not The Package: Contradictions In Public Opinion During Health Reform,” Health Affairs 2010;29(6):1125-30. Written and Class Preparation Work: Students assigned to present will be asked to present for 10 minutes on particular healthcare platforms during the Truman, Nixon, and Clinton administrations (including the goals of the proposal, who will be covered, and how it will be financed). Students assigned to these roles will present the major facets of the particular proposal at stake during each administration. Students should prepare a written outline of their presentation. In addition, each presenter should write a few paragraphs on which approach to health reform you personally think the U.S. should have taken and why that would have been the best choice. Deadline: The deadline for submission of the assignment to the Assignments link is Sunday, September 18th. Students not assigned to present on a healthcare platform will be assigned to represent the interests of one of the stakeholder groups historically involved with health reform efforts in the U.S. (e.g., the American Medical Association, small and large business groups, labor unions, hospitals, pharmaceutical companies, and/or consumer groups). From the perspective of your assigned stakeholder, consider the major health reform efforts in this country, up to and including the ACA. Write a brief (1-2 pages) about: (1) which approach to health reform was historically supported or opposed by “your” stakeholder group, (2) whether and how that approach changed during the debate over the ACA, and (3) which approach to health reform you personally think the U.S. should have taken and why that would have been the best choice. In addition, students representing stakeholders should come prepared to question presenters’ platforms from the perspective of your assigned stakeholder. Deadline: The deadline for submission of the assignment to the Assignments link is Sunday, September 18th. All students should be prepared to discuss your administration’s or stakeholder group’s approach to health reform both historically and currently (or, in some cases, as you think they might view health reform as it now stands), along with your own opinions, during the in-class discussion. In-Class Format: How did we get here? (60 minutes) Students assigned to present a Truman, Nixon or Clinton health care platform will provide a brief overview of their Administration’s particular proposal. Students who are assigned to represent particular stakeholders will pose questions of the presenters (based on their stakeholders’ positions.) At times, questioners may be asked to describe their stakeholders’ views of health reform and how they have evolved over time. What are we trying to accomplish, and why? (60 minutes) In-class discussion of the various components/mechanisms, policy choices, stakeholder interests, and values that have played, and continue to play, a role in designing and carrying out health reform efforts. We will consider questions including: • What is the appropriate role of government in achieving health insurance coverage for all Americans? • What are the implications of a health insurance system tied so strongly to employment? • Should access to affordable health care be considered a basic right? What would this mean? • How has public opinion influenced health reform policy choices? • How should the potentially competing goals of universal coverage and health care cost containment be balanced?

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• How has the American political system helped or hindered efforts at health reform? Has it been primarily the substance of reform proposals or the contemporary politics that have affected the outcome of reform efforts? • Were the challenges to (and challengers of) the ACA in the Supreme Court predictable, or even inevitable? We will end class with an open discussion as to which approach to health reform we each think the U.S. should have taken and why that would have been the best choice.

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CLASS 4: THE FUTURE OF PRIVATE HEALTH INSURANCE AND PUBLIC COVERAGE PROGRAMS Objectives 1. To provide a brief overview of our private and public health insurance systems. 2. To discuss trends in health insurance models and the future of the employer-based private health insurance system in a post-ACA health care environment. 3. To understand the role of states as laboratories for health reform and debate various perspectives on the appropriate future role and structure of Medicaid in addressing the needs of vulnerable populations. Assignments Reading Assignments (Tab 4): Private insurance • Alvarado, A. et al., “Examining Private Exchanges in the Employer-Sponsored Insurance Market,” Kaiser Family Foundation, September 2014,(SKIM, pages 1-11 only). • Gorman L., “Consumer-Directed’ Health Plans Appear to Lower Spending,” National Bureau of Economic Research Digest, July 2015. • Doss Helms, A., “High-Deductible Health Plans Can Ruin Finances,” Charlotte Observer/Kaiser Health News, April 6, 2015. • Keckley, P. et al., “The Future of health care insurance: What’s ahead?” Deloitte Review, July 24, 2013. • Pfeffer, J., “Why health insurance companies are doomed,” Fortune, October 20, 2014. Medicare and Medicaid • Health Affairs Health Policy Brief: The Oregon Health Insurance Experiment, July 16, 2015. • Sparer, M., “Medicaid at 50: Remarkable Growth Fueled by Unexpected Politics,” Health Affairs 34, No. 7 (2015) 1084-1091, July 2015. • Bindman, A., “Managing the Future of Medicaid,” JAMA, July 28, 2015. • Altman, D., “In La. And Ky. Shifts on Medicaid Expansion, a Reminder of Governors’ Power in Health Care,” Wall Street Journal, August 3, 2016. • Rosenbaum, S. et al., “The Promise and Pitfalls of Alternative State Approaches to Medicaid Reform,” Commonwealth Fund blog, June 11, 2015. • Frakt, A., “Gingrich’s Correct Prediction About Medicare’s Future,” New York Times – The Upshot, July 7, 2014.

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Optional readings (for more background/information): • Hancock, J., “High-Deductible Health Plans Cut Costs, At Least For Now,” Kaiser Health News/NPR, March 26, 2015. • Waldman, P., “Hobby Lobby Decision shows we need to get rid of the employer-based health insurance system,” Washington Post Plum Line, June 30, 2014. • Altman, D. and Frist, W., “Medicare and Medicaid at 50 Years: Perspectives of Beneficiaries, Health Care Professionals, and Institutions,” JAMA, 2015; 314(4) 384-395, July 28, 2015. • Center for Health Care Strategies, Inc., Toward 2014: Perspectives on Shaping Medicaid’s Future, May 2013. Written and Class Preparation Work: Students are assigned to play the role of either a state governor or a staff member of the National Governors Association (NGA) Center for Best Practices Health Division (who will be questioning a governor) for an in-class roundtable discussion on state approaches to Medicaid reform (including ACA Medicaid expansion and “traditional” Medicaid). Students playing governors will represent that governor’s position at the in-class roundtable; students playing NGA staff will pose questions to their assigned governor, designed to examine the rationale and likely efficacy of the governor’s approach. Governors will likely include: Matt Bevin (Kentucky), John Bel Edwards (Louisiana), Andrew Cuomo (New York), Charlie Baker (Massachusetts), Asa Hutchinson (Arkansas), Scott Walker (Wisconsin), Mike Pence (Indiana), and Kate Brown (Oregon). Students should submit a brief outline (1-2 pages, bullet points are fine) of either your governor’s position or questions for your assigned governor. Students may be paired in teams of two; in that case students should collaborate with their teammates and submit only one outline or set of questions per team. You are welcome to use any materials you can find to inform yourself of your governor’s perspective regarding Medicaid, Medicaid expansion, and how to meet the health needs of low-income, uninsured state residents (instructors will also provide a list of supplemental resources/readings). Deadline: The deadline for submission of your outline to the Assignments link is midnight, Sunday, September 25th. In-Class Format: Brief overview of private insurance, Medicaid, and Medicare and a discussion of trends in and the future of employer-based health insurance (60 minutes): Instructors will present a brief overview of private insurance and the two major forms of public health coverage (Medicaid and Medicare), including how they operate, some historical context, and key reforms that are occurring with implementation of the ACA. The class will then discuss emerging trends in health insurance models and the future of employer-based health insurance, assessing its strengths and challenges in a post-ACA health care environment. Governors’ Roundtable (60 minutes): In advance of the 2016 elections, the Health Division of the National Governors Association (NGA) Center for Best Practices is hosting a roundtable session to inform its development of recommendations concerning Medicaid policy that will be available to newly-elected governors. The NGA has invited governors from several states that have taken a range of approaches to Medicaid reform, in terms of both ACA Medicaid expansion and transformation of “traditional” Medicaid. Each governor will have three minutes to present on his or her main policy positions about Medicaid. NGA staff assigned to a governor will then pose questions, such as: to investigate whether or not specific Medicaid policies espoused by the governor are in fact the best approach in terms of meeting the health needs of state residents; to identify the impact of specific proposals on bending the cost curve of health expenditures; and/or to explore the impact of the governor’s proposals on different constituencies. Other roundtable participants – both governors and NGA staff – are also welcome to pose questions. Governors proposing or implementing policy change from their predecessors (e.g., in Kentucky and Louisiana) should

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be prepared to discuss how their approach differs from the previous administration, and what the implications of the policy changes might be. We will also “break character” after the roundtable to discuss your perspectives regarding the ACA Medicaid expansion, possible policy reforms/restructuring of Medicaid, and the appropriate role of government health programs in meeting the needs of vulnerable populations as well as dealing with health care costs and budget constraints.

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CLASS 5: DISCRETIONARY HEALTH PROGRAMS Objectives 1. To understand discretionary government health programs, how they relate to other public and private health insurance, and their current role in providing access to care for specific populations and services. 2. To understand the impact of the ACA on discretionary programs, as well as the ongoing role of discretionary programs in addressing gaps in access to care even after full ACA implementation. 3. To consider and discuss the rationale and implications of having disease-specific discretionary government health programs. Assignments Reading Assignments (Tab 5): • Napili, A., Title X (Public Health Service Act) Family Planning Program, Congressional Research Service, July 31, 2015. • Kristof, N., “Our Sex-Crazed Congress,” New York Times, August 1, 2015. • Pazzanese, C., “Disarray at the VA: Kennedy School’s Bilmes has pragmatic proposals for Presidential Commission System Overhaul,” Harvard Gazette, June 6, 2014. • Concerned Veterans for America, Fixing Veterans Health Care, 2014. (Skim Executive Summary pg. 7-16) • Cahill, S. et. al., “The Ryan White HIV/AIDS Program in the Age of Health Care Reform,” Am. Journal of Public Health, Vol. 105 No. 6, June 2015. • Centers for Medicare and Medicaid Services, Assuring Medicaid Beneficiaries Access to Hepatitis C (HCV) Drugs, November 5, 2015. • The Boston Globe editorial team, “Wider access to hep C drugs is humane and pragmatic,” July 29, 2016. Optional readings (for more background/information): • The Academy Health, The Future of Health Care for Military Personnel and Veterans, Aug. 2012. • Freyer, F., “State’s steps to control HIV seen as model for the nation,” The Boston Globe, January 15, 2015. • Dawson, L. and Kates, J., The Ryan White Program and Insurance Purchasing in the ACA Era: An Early Look at Five States, Kaiser Family Foundation, April 2015. In-Class Format: Overview and discussion of discretionary programs (20-30 minutes): Staff will present an overview of the different types of discretionary programs and how they operate, including some historical context and the major impacts that are occurring with implementation of the ACA.

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Guest speakers and class discussion (90-100 minutes): We will hear from guest speakers about the role and importance of discretionary health programs, and will discuss the health and policy implications of these programs in the context of changing health delivery and financing systems. Speakers may include: • an official from the Massachusetts Department of Public Health to talk about the Ryan White Program, the $2.2 billion federal program for HIV care, treatment, and services, and compare/contrast Ryan White with potential government responses/approaches to the hepatitis C epidemic, given the fact of viable (but extremely expensive) cures; • a speaker to discuss the ongoing need for Veterans Administration health programs, in light of Affordable Care Act implementation; • a speaker to discuss the recent efforts to cut funding from the Title X family planning program, and specifically to defund Planned Parenthood.

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CLASS 6: PUBLIC HEALTH, INFECTIOUS DISEASE EPIDEMICS, AND DISEASE CONTROL: ZIKA OUTBREAK AS A CASE STUDY Objectives 1. To provide a brief overview of the public health system in the U.S. and the tools used to advance its goals. 2. To understand the legal authority for public health interventions. 3. To use modern epidemics as a lens through which to understand the public health system. 4. To explore the dilemmas arising when individual rights conflict with public health goals. Assignments Reading Assignments: A Framework for Understanding Public Health in the U.S.: • The Wrong Rights, NEWSWEEK (Oct. 10, 1999). (available in course packet and on course website) • California Health Policy Forum, Understanding the United States Public Health System (2007). • Gostin, L., “Public Health Powers in the Modern Constitutional Era,” in PUBLIC HEALTH LAW: POWER, DUTY, AND RESTRAINT 131-135 (2008). (available in course packet and on course website) • City of Newark v J.S., 279 N.J. SUPER. 178 (1993). Ebola and Swine Flu: Two of the Most Recent Outbreaks • Hodge, J.S., et al, “Efficacy in Emergency Legal Preparedness Underlying the 2014 Ebola Outbreak” TEXAS A&M LAW REVIEW 353-383 (2015). • Chedekel, L. “Battling Ebola: the Ethical Issues” BU Today (Aug. 13 2014). • Rutkow, L., “An Analysis of State Public Health Emergency Declarations,” 104 AMERICAN JOURNAL OF PUBLIC HEALTH 9, 1601-1605 (September 2014). • Attkisson, S., “Swine Flu Cases Overestimated?” CBS (Oct. 21, 2009). • WORLD HEALTH ORGANIZATION DEPT. OF COMMUNICABLE DISEASE, WHO GLOBAL INFLUENZA PREPAREDNESS PLAN: THE ROLE OF WHO AND RECOMMENDATIONS FOR NATIONAL MEASURES BEFORE AND DURING PANDEMICS (2005) (Executive Summary Only). Zika Virus: The Newest Epidemic • Monroe, S., et al, “Zika Preparedness and Response: A Public Health and Legal Perspective,” AMERICAN PUBLIC HEALTH ASSOCIATION (March 18, 2016). Note: See optional materials below for the recorded accompanying webinar.

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• Petersen, E., et al, “Unexpected and Rapid Spread of Zika Virus in The Americas – Implications for Public Health Preparedness for Mass Gatherings at the 2016 Brazil Olympic Games,” INTERNATIONAL JOURNAL OF INFECTIOUS DISEASES (2016). • Lucey, D. and Gostin, L., “The Emerging Zika Pandemic: Enhancing Preparedness,” JAMA (January 27, 2016). • McNeil Jr., D., “Puerto Rico Braces for Its Own Zika Epidemic,” NEW YORK TIMES (March 19, 2016). • White House, “Fact Sheet: Preparing for and Responding to the Zika Virus at Home and Abroad,” OFFICE OF THE PRESS SECRETARY (February 8, 2016). • Sun, L., et al, “CDC Issues a Travel Advisory to Florida, Which has 10 New Cases of Zika,” The Washington Post (August 1, 2016). • Various Authors, Compilation of Recent Zika News Articles (August 2016). (available in course packet) Optional Materials: Monroe, S., et al, “Zika Preparedness and Response: A Public Health and Legal Perspective,” AMERICAN PUBLIC HEALTH ASSOCIATION (March 18, 2016). Note: This is a recorded one hour webinar using the slides assigned above. It will be very helpful for the summit, although you should be adequately prepared by just reviewing the slides and other readings. Contagion Trailer (2011). Note: If you have time, this is a great movie to watch before this class. The movie was produced in response to the H1N1 outbreak out of concern that Americans did not understand the gravity of the threat a true epidemic would present. Written and Class Preparation Work: Summit: Health Policy Convening on Zika Outbreak Background: It’s the summer of 2016. Zika is constantly in the news. Unfortunately, summer is when mosquitos are most active and Zika infections are most likely to occur. Today the Florida health department reported several new cases of local Zika infections, bringing the total number of cases in Florida for 2016 up to fifteen. The Florida Surgeon General and Secretary of the Department of Health, Celeste Philip, reported that all of these cases have come from a densely populated community just north of Miami. In general, panic is increasing. Suggestions as to how to address this potential epidemic have ranged from recommending that all women in Miami postpone childbearing, issuing a travel warning to Miami, isolating identified living patients, initiating a mass screening initiative, spraying for mosquitos, genetically modifying the local mosquito population to reduce their numbers, and suggesting that all pregnant women remain indoors. Because of the high profile of this outbreak, the Director of the CDC, Thomas Frieden, has brought some key individuals to a meeting to develop a coordinated plan of action to address the Florida outbreak at the federal, state, and local levels. This is a challenging assignment, due to the different concerns and perspectives of the parties attending the meeting, but Frieden is hoping the meeting participants can develop a proposed coordinated plan of action that can serve as a model for addressing Zika in the United States

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should Zika spread to other parts of the country. Director Frieden has prepared an outline consisting of the challenges facing the federal, state, and local governments as well as the public health community as they attempt to address the zika epidemic in Florida. This outline will be used to guide the summit discussion. Director Frieden has invited the following people to the meeting: Rick Scott (the Governor of Florida), Celeste Philip, Tomas Pedro Regalado (the Mayor of Miami), Bill Nelson and Marco Rubio (Florida’s U.S. Senators), and Dr. Pierre Buekens, (the Dean of the Tulane School of Public Health and Tropical Medicine). At the end of the summit Director Frieden should be prepared to present the action plan created at the summit to the President. For students assigned to play Thomas Frieden: Complete a 1-2 page outline to guide your summit discussion. These outlines should note what challenges face the summit participants as they attempt to address the zika epidemic as well as outline potential next steps. For all students: Everyone will be assigned to the role of one of the meeting attendees at the end of Class Five. Prepare a brief policy paper (1-2 pages) explaining what you think your assigned character would say is the best plan of action and why? What is the legal authority for each proposed action step, if any (ie, are there action steps that are necessary where no clear legal authority exists)? Will your character’s suggested action steps face pushback and, if so, from whom (individuals and/or interest groups)? Also, at the end of your policy paper, please explain what you think is the right course of action. Again, this might include taking actions you think are necessary to protect the public’s health that are not specifically authorized by law. Deadline: All students submit an outline or policy paper (depending on your assigned role) and an opinion statement to the Assignments link by midnight, Sunday, October 16th. In-Class Format: Lecture & Discussion (60 minutes): We will briefly go through the basics of public health in the U.S., and then begin an interactive discussion related to the use of the law to promote public health, particularly as it relates to communicable diseases such as Ebola and influenza. Zika Outbreak Small Groups (30 minutes): Students will get into small groups consisting of one of each of the assigned roles. Each group will spend thirty minutes negotiating a plan to address the potential epidemic, with each student acting in character and consistent with their written position statement. The student playing Director Frieden will lead the discussion, using the outline prepared before class as a discussion guide.Each group should come up with a list of appropriate next steps to be taken. Zika Outbreak Discussion (30 minutes): Each group will have five minutes to present their action plan to the class. The student playing Director Frieden will be presenting the action plan created by the group, outlining next steps and explaining why the group choose this particularcourse of action. Following each presentation, students will be given the opportunity to ask questions and challenge the decisions of the presenting group. Remember—there is no right answer here! The best action plans will be justifiable using principles from the readings and be consistent with the concerns of the characters you are asked to play. After the summit we will break out of roles and have an open discussion as to what you think is an appropriate domestic response to Zika as well as how you think the outbreak is actually being handled by federal and state government officials.

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CLASS 7: PUBLIC HEALTH: PREVENTION AND ADDRESSING HEALTH DISPARITIES: OBESITY AS A CASE STUDY

Objectives 1. To understand the concept of health inequities/disparities in the U.S., including causes outside of medical care and behavior (social and economic factors) that contribute to poor health outcomes, current projects addressing social determinants of health, the benefits of improving socioeconomic status and health for the U.S., and the potential of alternative policy solutions. 2. To understand the dynamics of disease prevention. Assignments Reading Assignments (Tab 7): Overview of ACA Prevention Initiatives, Social Determinants of Health and Health Disparities – Obesity as a Case Study: • Koh, H., et. al., “Promoting Prevention through the Affordable Care Act,” New England Journal of Medicine, 363, no. 14 (September 30, 2010): 1296-1299. • “Preventive Services Covered Under the Affordable Care Act,” HealthCare.gov, January 2011. • Heiman, Harry J. and Samantha Artiga, “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity,” Kaiser Commission on Medicaid and the Uninsured, (Nov. 2015). • “Fact Sheet: Health Disparities in Obesity,” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011, p.1. • Seligman, H., et. al., “Hunger and Socioeconomic Disparities in Chronic Disease,” New England Journal of Medicine, 363, No. 1 (July 2010): 6. The Role of Personal Responsibility: • Epstein, Richard A. Richard A. Epstein, “What (Not) to do About Obesity: A Moderate Aristotelian Answer,” The Georgetown Law Journal, 93 (2004-2005): 1361-1385. (Available in course packet and on course website.) EXCERPT. • Moss, M., “The Extraordinary Science of Addictive Junk Food,” New York Times, February 20, 2013. • Brownell, K., et. al., “Personal Responsibility and Obesity: a Constructive Approach to a Controversial Issue,” Health Affairs, 29, no. 3 (March 2010): 379-387. Responses to the Obesity Epidemic: • “Gov. Blagojevich Signs Illinois Common Sense Consumption Act,” Illinois Government News Network, July 2004. • Commonsense Consumption Act, H.B. 683/Session Law 2013-309, General Assembly of North Carolina, Session 2013 (July 18, 2013).

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• Gogolak, E., “Appeals Court Rules Against Bloomberg Beverage Restrictions,” New York Times, July 13, 2013. • Neuman, W, “U.S. Seeks New Limits on Food Ads for Children,” New York Times, April 28, 2011. • “US FTC Weakens Proposals for Food Ads to Children,” Reuters.com, October 11, 2011. • Frieden, T., et. al., “Reducing Childhood Obesity Through Policy Change: Acting Now to Prevent Obesity,” Health Affairs, 29, no. 3 (March 2010): 357-363. • Tavernise, S., “Poor Children Show a Decline in Obesity Rate,” New York Times, August 6, 2013. • Smith, Noah, “Big Government, Small Bellies: What Japan Can Teach Us About Fighting Fat,” The Atlantic, Sep. 6, 2012. • Guthrie, Amy and Mike Esterl, “Soda Sales in Mexico Rise Despite Tax,” Wall Street Journal, May 3, 2014. Battle for the Soul of SNAP: • Building a Healthy America: A Profile of the Supplemental Nutrition Assistance Program, United States Department of Agriculture, April 2012, pgs. 1-5. • Lowrey, A., “How Conservatives Learned to Love the Federal Food Stamps Program,” Slate.com, December 10, 2010. • Black, J., “SNAP Judgment,” Slate.com, August 6, 2013. • Johnson, Natalie. “Hold the Lobster. This New York Legislator Wants to Prevent ‘Luxury Purchases’ with Food Stamps,” The Daily Signal, Feb. 22, 2016. • “SNAPSHOT of the WIC Food Packages,” USDA Food and Nutrition Services, as of Oct. 10, 2015. • Confessore, N., “Minority Groups and Bottlers Team Up in Battles Over Soda,” New York Times, March 12, 2013. • “Healthy Incentive Pilot (HIP) Interim Report,” USDA Food & Nutrition Service Office of Policy Report, July, 2013. [EXCERPT: Executive Summary pp. 1-5] Written and Class Preparation Work: Debate: Limiting the Use of SNAP Benefits Background: Obesity and diet-related diseases are among our nation’s most pressing public and individual health concerns. In response to these concerns, over the past decade several cities and states have attempted to limit the purchase of certain foods and beverages with SNAP benefits (formerly Food Stamps). To date, the USDA has rejected all applications for waivers that would limit the use of SNAP benefits, yet the debate over placing restrictions on the use of SNAP benefits is ongoing. Harvard Law School is sponsoring a debate on the issue.

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For Debaters: Each Debater is assigned a character of an important guest speaker to research and represent during the debate. Three guest speakers are in support of restricting SNAP purchases (former Mayor Michael Bloomberg, a representative from the American Medical Association, and Marion Nestle, Professor in the Department of Nutrition, Food Studies, and Public Health at NYU) and half in opposition (Thomas Vilsack, Secretary of the U.S. Dept. of Agriculture, a representative from the American Beverage Association, and Joel Berg, Executive Director of the NYC Coalition Against Hunger.) Draft an outline of argument about why your character supports or opposes limiting the purchase of certain foods and beverages with SNAP benefits. To the extent possible, address the impact your argument has on individual and public health as well as on addressing health disparities. Also, to the extent possible address arguments in support of opposition to the charge that obesity and diet-related health conditions are largely a matter of individual choice and personal responsibility. Finally, at the end of your outline, briefly explain what you think is the right course of action. For Questioners: Prepare at least one question for two characters with opposing views in the debate. You do not need to submit your questions to the Assignments link but are welcome to read the debate outlines submitted by debate participants prior to class to help you prepare your questions. All Students: Prepare and submit a paragraph or two explaining what you think is the right course of action in the SNAP debate. Deadline: Submit your outline (Debaters) and/or your opinion statement (all students) to the Assignments link by midnight, Sunday, October 23th. * Students should also submit their Class 11 or 12 policy paper outline by midnight, Sunday, October 23th.

In-class Format Lecture (60 minutes): During the first hour, clinical instructors will provide an overview and facilitate a discussion on public health prevention efforts versus individual health services. Topics will include the rationale for the exercise of public health powers that interfere with individual rights, what are the appropriate limits to such powers considering the balance between public gains and individual rights, as well as cost implications to our society. The discussion will also include an overview of determinants of health (and contributor to disparities in health) and the relationship between how we live our lives and the economic, social and physical environments in which we live. Together we will attempt to define what we mean by disparity, what disparities look like and why they exist, as well as policy solutions to address social determinants of health and the reduction of racial health disparities. Debate (60 minutes): Students will debate the merits of limiting the use of SNAP benefits. The moderator will open the debate with a brief introduction of the issue. Students will then have the opportunity to present a very brief opening statement (if possible, please refrain from reading written statements), and then the moderator will pose questions to each side. Students on the pro and con sides will also be able to ask questions of their colleagues on the other side. At times, the moderator will turn to the audience to solicit questions for the panelists. At the end of the debate we will have an open discussion of our personal opinions on this issue.

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CLASS 8: SCIENCE VERSUS POLITICS AND THE PURSUIT OF PUBLIC HEALTH Objective 1. To understand the complicated dynamics of issues at the nexus of public health and political ideology, including HIV criminalization statutes, sexual education curriculum in schools, and gun control. Assignments Readings Assignments (Tab 8): Overview: • SKIM: James Morone, Hellfire Nation: The Politics of Sin in American History, Chapter 1. (Available in course packet and on course website.) Sexual Education: • Constantine, N., et. al., “Sex Education: The Parent’s Perspective,” May 2007. • Santelli, J., “Medical Accuracy in Sexuality Education: Ideology and the Scientific Process,” 98 AM. J. PUBLIC HEALTH 1786 (2008). • Stein, R., “Abstinence-only programs might work, study says,” THE WASHINGTON POST, Feb. 2, 2010, § A, at 1. • Salek, C., “More Proof That Comprehensive Sex Education is the Only Kind That Works,” Policy Mic, July 2013. • US House of Representatives Committee on Government Reform, The Content of Federally Funded Abstinence-Only Education Programs, December 2004. • Jenkins, V., “Legislation passes requiring N.C. sex education to link abortions to preterm births,” THE FAYETTEVILLE OBSERVER, July 11, 2013. • Schmidt, C., “Colorado Teen Birth Rate Drops 40% With Low-Cost Birth Control,” CNN.COM., July 10, 2014. • Letter from Robert Greenwald, Co-Chair, Access to Care Subcommittee, PACHA and Kathie Hiers, Co-Chair, Subcommittee, PACHA, to Evelyn Kappeler, Director, Office of Adolescent Health, HHS, et al. (Apr. 10, 2014). Criminalizing Knowing Transmission of HIV: • Mesika, R., “The Ethics of HIV Criminalization,” International Center for Ethics, Justice, and Public Life (July 2012). • CRIMINALIZATION OF HIV TRANSMISSION, UNAIDS POLICY BRIEF (Aug. 2008).

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• Berger, P., “Prosecuting for Knowingly Transmitting HIV is Warranted,” 180 CANADIAN MED. ASS’C. J. 1368 (2009). • Wainberg, M., “Criminalizing HIV Transmission May Be a Mistake,” 180 CANADIAN MED. ASS’C. J. 688 (2009). Gun Control • READ SYLLABUS ONLY: District of Columbia v. Heller, 554 U.S. 570 (2008). • Rose, V., “Summary of D.C. v. Heller,” OLR Research Report (Oct. 2008). • Pérez-Peña, R., “Gun Control Explained,” THE NEW YORK TIMES (Oct. 7, 2015). • Hartman, M., “How Australia and Britain Tackled Gun Violence,” NYMAG.COM (Oct. 2015). • Defilippes, E. & Hughes, D., “New Study Is Latest to Find that Higher Rates of Gun Ownership Lead to Higher Rates of Violent Crime,” THE TRACE (June 2015). • Riddel, K., “Chicago Crime Rate Drops as Concealed Carry Applications Surge,” THE WASHINGTON TIMES (Aug. 2014). • Robbins, Mel, “The Real Gun Problem Is Mental Health, Not the NRA,” CNN.COM (June 2014). • Metzl, J & MacLeish, K., “Mental Illness, Mass Shootings, and the Politics of American Firearms,” 105 American J. of Public Health 240-249 (Feb. 2015). Optional Additional Readings/Resources: • Real Education For Healthy Youth Act (2013). • Podcasts: Avirgan, J., “Seven Conversations about Preventing Gun Deaths,” FiveThirtyEight (Jul.

2016). Class Preparation Work and In-Class Format Focused Discussions: During class 8 we will be having focused discussions on each of three potentially controversial policy responses to public health crises: (1) statutes criminalizing the knowing transmission of HIV; (2) sexual education curriculums in schools; and, (3) gun control. Through the discussions we will examine the various ways in which the federal government and states have advanced (or not advanced) public health policy to address communicable diseases (such as HIV, STDs, and measles), sexual and reproductive health, and gun violence. For each of the issues, there are clear proponents and opponents (both within government and in the community) advocating for or against the use of these responses and we will discuss their role in both influencing and implementing public health law and policy. Preparation Work for Proponents and Opponents during Each Discussion: At the beginning of each discussion, assigned students will briefly present opening statements on the key arguments for and against the policy response. For these opening statements, there will be two teams of students assigned to present on each issue: one team that will present the key arguments in support of the solution, and one team that will present the key arguments against the solution.

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After these opening statements, we will open the issue to the class for discussion. However, we ask that students assigned a role remain in their roles during the open discussion to ensure that we have both proponent and opponent viewpoints represented. Please note that there is no written assignment for this class, although we encourage students to perform outside research to prepare for the opening presentations, and an outline may be helpful to you.

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CLASS 9: PUBLIC HEALTH AND THE COURTS

Objectives 1. To understand the tools to advocate for improved public health through the courts rather than through legislative change, and how these tools are utilized. 2. To compare different ways that basic public health and access to health care issues are presented to courts, and analyze the boundaries that judges impose on efforts to increase access.

3. To understand what efforts judicial systems have undertaken in the area of overlap between criminal law and public health concerns. Assignments Reading Assignments (Tab 9): Litigation to Enforce Health Care Rights: • Armstrong v. Exceptional Child Ctr., Inc., 135 S. Ct. 1378 (2015). • Centers for Medicare and Medicaid Services, “Assuring Medicaid Beneficiaries Access to Hepatitis C (HCV) Drugs, State Release 172.

• B.E. v. Teeter, No. C16-227-JCC, 2016 WL 3033500 (W.D. Wash. May 27, 2016).

• Text of Section 1557 of the Affordable Care Act

• Rumble v. Fairview Health Services, No. 14–cv–2037, 2015 WL 1197415 (D. Minn. March 16, 2015). Going Beyond the Courts to Address Public Health: • Stephen Hunter et. al., New Jersey's Drug Courts: A Fundamental Shift from the War on Drugs to A Public

Health Approach for Drug Addiction and Drug-Related Crime, 64 Rutgers L. Rev. 795 (2012).

• Drug Policy Alliance Report: “Drug Courts are Not the Answer: Toward a Health Centered Approach to Drug Use” (2011). • White House Fact Sheet: Enhancing the Fairness and Effectiveness of the Criminal Justice System (July 14, 2015).

Written and Class Preparation Work: Write a short (one to two pages) analysis of one of the judicial decisions included in the readings, either in support or as a criticism. Describe how the decision promotes or harms public health. Deadline: Submit your analysis to the Assignments link by midnight, Sunday, November 6th.

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In-Class Format Lecture: (30 minutes) Instructors will provide an overview of the myriad ways courts and public health are increasingly intertwined. Class Discussion/Presentations: (90 minutes) Students will present their critiques and facilitate a class discussion on how the law, policy, opinion, or brief promotes or harms public health.

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CLASS 10: ECONOMICS OF HEALTH CARE – DRIVERS OF SPENDING AND POLICY LEVERS: FINANCE, PAYMENT AND DELIVERY REFORMS Objectives: 1. To understand why the U.S. spends more on healthcare and gets less than any other country. 2. To understand the barriers to reducing cost. 3. To examine some attempts to reduce cost, and their efficacy (especially in the context of expanding coverage). Assignments: Reading Assignments (Tab 10): Understanding What the U.S. Spends on Healthcare and Why: • Squires, David and Chloe Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries, THE COMMONWEALTH FUND, Oct. 2015. • Porter, Eduardo., Health Care’s Overlooked Cost Factor, THE NEW YORK TIMES, Jun. 11, 2013. • Hancock, Jay. In Battle of Health Care Titans, Should Insurers Act Like Wal-Mart? NPR, Aug. 11, 2016. • SKIM: Brill, S., Bitter Pill: Why Medical Costs Are Killing Us, TIME, Mar. 4, 2013. (Available in course packet and on course website.) • Gawande, A. The Cost Conundrum, THE NEW YORKER, Jun. 1, 2009. • Himmselstein, David and Steffie Woolhandler, The Post-Launch Problem: The Affordable Care Act’s Persistently High Administrative Costs, HEALTH AFFAIRS BLOG, May 27, 2015. • Whalen, Jeanne. Why the U.S. Pays More Than Other Countries for Drugs, WALL STREET JOURNAL, Dec. 1, 2015. • The Impact of Direct-to-Consumer Advertising, U.S. FOOD AND DRUG ADMINISTRATION, (as of Aug. 12, 2016). • AMA Calls for Ban on Direct to Consumer Advertising of Prescription Drugs and Medical Devices, AMERICAN MEDICAL ASS’N, Nov. 17, 2015. Opportunities for Improvement: • Chernew, M., Value-Based Insurance Design, 26 HEALTH AFFAIRS 2, w195-w203 (2007). • A Closer Look at Alternative Payment Models, MILKEN INSTITUTE FASTERCURES CENTER, 2014. • Tu, Tianna et al., The Impact of Accountable Care: Origins and Future of Accountable Care Organizations, LEAVITT PARTNERS WITH ROBERT WOOD JOHNSON FOUNDATION, May 2015.

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• Mechanic, Robert M., When New Medicare Payment Systems Collide, 374 NEW ENGLAND J. MEDICINE 18, 1706-1709 (May 5, 2016). • Summers, Daniel, I’m a Doctor. Here’s Why I Oppose the Single-Payer Revolution, THE NEW REPUBLIC, Feb. 19, 2016. • Gaffney, Adam, How Liberals Tried to Kill the Dream of Single-Payer, THE NEW REPUBLIC, Mar. 8, 2016. • Islam, Ifrad, Rising Cost of Drugs: Where Do We Go From Here?, HEALTH AFFAIRS BLOG, Aug. 31, 2015. • Dodge, John. New website helps patients comparison shop for health care, BOSTON GLOBE, Apr. 3, 2016. • Shannon, Maribeth, Only Skin Deep: Why Patients Don’t Shop for Healthcare, C.A. HEALTHCARE FOUNDATION, Mar. 11, 2015. • Galloway, Ian, Using Pay-for-Success to Increase Investment in the Nonmedical Determinants of Health, Health Affairs, 33 no. 11 2014: 1897-1904. Optional • Gawande, Atul. Overkill, THE NEW YORKER, May 11, 2015. In-Class Format: Lecture/Class Discussion (120 minutes): Clinical instructors will provide an overview and facilitate a discussion on cost drivers in health care. We’ll examine a few attempts at payment reform and discuss what has and has not worked.

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CLASS 11: INNOVATIVE SOLUTIONS TO ONGOING BARRIERS TO ACCESS TO CARE Objectives 1. To understand a broad range of ongoing barriers to access to health care and the impact such barriers have on the health of specific sub-populations. 2. To explore the complexity of working to generate solutions to federal, state or local health care access challenges. 3. To generate concrete proposals for addressing changes to ACA or other parts of our health care delivery system that are necessary in order to reduce barriers to access to health care. Assignments Readings Assignments: A few short articles on innovative solutions to ongoing barriers to access to care will be distributed later in the semester. Topics covered could include efforts to address the following: • Immigrant health • Women’s health • Prison health – transition out of incarceration • Inadequacy of coverage – as a result of services not covered, insufficient access to specific types of providers, or due to increasingly high beneficiary co-payment obligations • Non-expansion states – coverage gap issues The primary reading assignment is for all students to read all of the policy papers prior to class. Written Assignment: Half the class will select a policy solution of their own choosing aimed at increasing access to care or improving health outcomes, especially among low-income populations. Students will write a four-five page single-spaced policy brief describing the policy solution and how it would be implemented. Policy solutions should be specific, targeted, and potentially achievable (i.e., not “the U.S. should have a single payer health system”). Focus on “smaller” solutions to reduce barriers to care that have a realistic chance of being implemented. The paper should explain how the policy solution would fit into existing policies, statutes, or regulations and what new law(s) or regulation(s) would need to be enacted, if any. Deadline: Submit your policy paper to the Assignments link by midnight, Thursday, November 17th. In-Class Format Student Presentations: Each student will have approximately 10 minutes to lead a discussion on the policy solution he or she wrote about. Bearing in mind that all students will have read the paper prior to class, students should provide only a very brief summary of the paper prior to facilitating a discussion on the innovation solution’s strengths and challenges.

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CLASS 12: INNOVATIVE SOLUTIONS TO PUBLIC HEALTH CHALLENGES Objectives 1. To understand ongoing challenges to efforts to address public health and the impact such challenges have on health outcomes. 2. To explore the complexity of generating successful solutions to public health challenges. 3. To generate innovate proposals for addressing ongoing public health challenges.

Assignments: Readings Assignments: A few short articles on innovative solutions to ongoing public health challenges will be distributed later in the semester. Topics covered could include the following: • Tobacco control – including increased regulation of tobacco products, efforts to prevent youth smoking, regulating novel nicotine products, the role of agriculture policy in tobacco control • Mental health and/or substance use – federal and state parity laws, innovative treatment options, • Abortion • Gun control • HIV and STIs • Obesity • Access to healthy food • Environment • Global issues The primary reading assignment is for all students to read all of the policy papers prior to class. Written Assignment: Half the class will select a policy solution of their own choosing aimed at addressing an ongoing public health challenge. Students will write a four-five page single-spaced policy brief on how a city, state, or the federal government could implement the policy solution, including what new law(s) or regulation(s) would need to be enacted, if any. Describe where the new policy, as well as any new law or regulation, would fit into existing policies, statutes, or regulations, how they should be implemented and evaluated, and how they should be funded. As an alternative, you can write a critique of an existing public health law or regulation that has been enacted in order to further the policy goal of addressing an ongoing public health challenge. Describe how the law or regulation was implemented, including commenting on any trade-offs that were made in implementation. You can also discuss the timeline of the proposal, how it will be evaluated, whether and how fully it was funded, and any other problems with implementation. Deadline: Submit your policy paper to the Assignments link by midnight, Thursday, November 24th. In-Class Format

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Student Presentations: Each student will have approximately 10 minutes to lead a discussion on the policy solution he or she wrote about. All students will have read the papers prior to class, so students should only provide a very brief summary of the paper prior to facilitating a discussion on the innovation solution’s strengths and challenges.

Greenwald, Robert Public Health Law and Policy Fall 2016 seminar