• What is economics Go through for a general introduction to "the economic problem." (Alternative talking version. Loads slower.)
• Stocks and flows Dry, but helps with the next one.
• The Gross Domestic Product Go through for a general discussion of how this important economic statistic is conceived.
• U.S. National Health Spending in 2008:
• Lecture notes I talk you through the most recent numbers for the size and shape of the U.S. health care system.
  
• Data source: The U.S. Centers for Medicare and Medicaid Services economic statistics. Optional. Go here if you want to get more technical explanation or more numbers.
• Pie charts showing where health care money comes from and where it goes. Glance at this.
• Much of the recent growth in health care spending has been for expanding care for five conditions A quick look at this is OK. Here is the summary table of the fastest-growing diseases. Fastest growing in terms of spending, that is.
• A diagram, based on an earlier version of this next article, of sources of U.S. health care funding, 1995. Glance at this.
• Cathy A. Cowan and Micah B. Hartman, "Financing Health Care: Businesses, Households, and Governments, 1987-2003," Health Care Financing Review, Web Exclusive, July 2005, Volume 1, Number 2. Pages 1 and 2 explain their method. Page 4 has the table that shows how the my diagram's second column would have changed. This analysis has not been redone since, so far as I know.
• Health Spending in the United States and the Rest of the Industrialized World, by Gerard F. Anderson, Peter S. Hussey, Bianca K. Frogner, and Hugh R. Waters, Health Affairs, 2005, Vol 24, Issue 4, 903-914. A USC campus computer may be required to download this. Glance at this article. We'll talk about it near to the end of the course. This article shows how much more the U.S. spends on health care than other countries. The article debunks some myths that are dear to the anti-reform crowd, particularly (1) that people in other countries wait longer and get less service than Americans do, and (2) that big malpractice tort awards are why U.S. health care costs so much. In class, I'll show these diagrams, that are based on the article's data: Health spending and infant mortality, health spending and nurses, health spending and CT scanners.
• Meredith Minkler, Esme Fuller-Thomson, and Jack M. Guralnik, "Gradient of Disability across the Socioeconomic Spectrum in the United States," N Engl J Med, 355:7, Aug. 17, 2006. Alternative PDF link A little economics of health, rather than just the economics of health care.
• Paul Krugman, Live Long and Prosper, August 13, 2010. The prosperous live longer, so the poor lose the most when the Social Security eligibility age is raised. A diagram. The CBO report.

• Cost, opportunity cost; total, fixed, variable, and marginal cost Especially for those new to economics or needing a review. Go through this lecture for a introduction to these basic economics concepts. If your browser freezes when you try to load this, use the no-sound version.
  Cost slideshow:
  Cost.pptx
  Cost.ppt
  Cost.pdf
• Interactive tutorial on fixed, variable, and marginal cost Also for those who are new to economics or needing a review.

• Reinhardt, U.E., "Perspective: Spending More Through 'Cost Control': Our Obsessive Quest to Gut the Hospital," Health Affairs, Summer 1996, 15(2), pp. 145-154. A worthwhile article. You see how a top-notch economist thinks. Relevant for this week is how the author uses the "incremental cost" (marginal cost) concept.

• External cost and benefit Read this brief run-down of these concepts.
• The Center for Disease Control's Morbidity and Mortality Weekly Report, August 22, 2008, says that measles outbreaks in the U.S. are spreading more than they used to because fewer children are getting vaccinated.

• Discounting the future This tutorial and the next are valuable for this course and for courses in finance.
• Internal Rate of Return

Optional:
• Perils of the Internal Rate of Return

• Axnick, N.W., Shavell, S.M., Witte, J.J., "Benefits Due to Immunization Against Measles," Public Health Reports, August 1969, 84(8), pp. 673-680. Read. See how the authors use the idea of discounting future spending. See what they include as the costs and benefits of measles immunizations, especially how they value lives saved.
• Recent news: Measles Inoculation Campaign in China Resisted

• Cost-benefit analysis, including comments on the Axnick reading's methods and ethics. Go through this. If it doesn't load properly, try the no-sound version.
• The Colbert Report, July 14, 2008, on the declining value of life in the 2000's. Colbert talks about what is called a "hedonic" life value. Rather than a life value based on the present value of expected future earnings, a hedonic life value is based on the difference between what dangerous jobs pay and what safer jobs pay. We'll discuss this in class. Here is the 1976 article that originated the method. (Original.) Here is a report about a recent U.S. Labor Department study of which jobs are most life-threatening.

• Cost-effectiveness analysis, including comments on the Neuhauser reading's methods and ethics. Go through this. If it doesn't load properly, try the no-sound version.
• Notes on the Blackboard readings below. There is a no-sound version will load faster.

• Neuhauser, D., Lewicki, A.M., "What Do We Gain from the Sixth Stool Guaiac?" N Engl J Med, July 31, 1975, 293(5), pp. 226-228. Read pretty thoroughly. The notes (see above) will help with this.
• Eddy, D.M., "Screening for Cervical Cancer," Annals of Internal Medicine, August 1, 1990, 113(3), pp. 214-226. More technical. Don't get bogged down in technical detail. See the notes for help with this.
• Fries, J.F., Koop, E., et al, "Reducing Health Care Costs by Reducing the Need and Demand for Medical Services," N Engl J Med, July 29, 1993, 329(5), pp. 321-325. The authors are renowned public health leaders. This is conventional wisdom. But is it right?
• Russell, L.B., "The Role of Prevention in Health Care Reform," N Engl J Med, July 29, 1993, 329(5), pp. 352-354. Worth a fairly careful read. What is the basis of Russell's disagreement with the conventional wisdom?
• Huntington, J., Connell, F.A., "For Every Dollar Spent -- The Cost-Savings Argument for Prenatal Care," N Engl J Med, Nov. 10, 1994, 331(19), pp. 1303-1307. Also questions conventional wisdom.
• Eddy, D.M., Oregon's Methods: Did Cost-effectiveness Analysis Fail?. JAMA, Oct. 16, 1991, 266(15), pp. 2135-2141. See the notes for background and explanation.

• Beyond PAP tests: A study of the potential cost-effectiveness of HPV vaccine. The study gives results with and without the discounting of benefits that Eddy does in his PAP test study. Cost-effectiveness is judged by dollars saved per quality-adjusted year of life saved. That compares the vaccine with all efforts to save lives, rather than comparing the vaccine specifically with other methods to control HPV transmission or cervical cancer.
• Jane J. Kim, and Sue J. Goldie, "Health and Economic Implications of HPV Vaccination in the United States," New England J Med Aug 21 2008;359:821-32
• Report on the Net Cost of Smoking in the Czech Republic, July 2001. Large type version.In cost-effectiveness analysis, you have to be sure you know whose costs you are weighing. Read quickly for main ideas.
• Audio of discussion of the report's economics, politics, and ethics on NPR Planet Money, July 16, 2010. It starts at 3:52 in the recording.
• Chicken pox immunizations save $100 million in annual hospital cost. Is that enough to make immunizations a net saver of health care cost? Glance at this.
• A Washington Post story from 2007: "For the Want of a Dentist"
• Prevention can save lives, and this one may save money, too: Finland reduced deaths from strokes and heart attacks by 75%, by working with the food industry to reduce salt. (The linked article I had was too much of a curve ball. Sorry!) If that also meant fewer strokes, angina, and infarctions requiring surgery, health care spending would be less, too. The New England Journal of Medicine, Sept. 1. 2009, has an article about hypertension in the U.S., where salt intake per person has increased 50% in the past 30 years.
• Donna Richter, Prevention Key to Health Care Reform, The State, August 29, 2009. During 2009's health care reform battle, a version of the Fries-Koop argument.
• Arguments like that weren't just a distraction from the campaign to enact health insurance reform, they may have fed the paranoia about "death panels" that the opposition exploited. If you'd like a reminder of that craziness, here is Jon Stewart interviewing Betsy McCaughey (pronounced "McCoy") on the Daily Show August 20, 2009: Part 1 as aired | Part 2 as aired.
• The Right is pushing the fear for the 2010 election. On July 23, 2010, Rachel Maddow showed U. S. Representative Louie Gohmert (R - TX) fretting that the government will be penalizing people with high cholesterol who buy bacon.

• The Context of Studying Supply and Demand, a segue from cost-benefit analysis to market analysis. Go through this and the next two. They are like a class lecture without the talking head.
• Markets, supply, and demand
• Supply and demand
• Demand tutorial
• Notes on need and demand, and on elasticity
Elasticity notes for class display
• Elasticity concept interactive tutorial
• Elasticity calculation interactive tutorial

• General notes on what makes health care special
• Risk
• Risk Aversion
• Insurance concepts

• Bodenheimer, T., Grumbach, K., "Paying for Health Care," JAMA, August 24/31, 1994, 272(8), pp. 634-639.

• Arrow, K., "Uncertainty and the Welfare Economics of Medical Care," American Economic Review, December 1963, 53(5), pp. 941-973. Important. But difficult. The notes (see below) will help.

• Uwe Reinhardt's August 2010 comment on Arrow's ideas, part 1.
• Uwe Reinhardt's August 2010 comment on Arrow's ideas, part 2.
• Notes on Arrow reading
• An audio clip from Car Talk (9/10/05) about letting people choose anyone they want to be their doctor. Is this a great idea?
• Uwe Reinhardt's August 2010 follow-up about how economists use the term "efficiency."

These readings show that people do get less health care when they have to pay more. Theory of demand does apply. There is a demand curve for health care generally and there are demand curves for specific types of health care. These demand curves slope down from left to right. To use the jargon, the demand for health care has some elasticity. The elasticity is pretty low, especially for people seeking care for serious symptoms, but it's not 0.

The articles go on to investigate whether people who buy less care, because they have to pay more, are worse off as a result. If the answer is No, then letting people get care without paying out of pocket is wasteful. Or is it? Are all the costs being considered? How good are people at determining what care they can do without?

• Brook, R.H., et al, "Does Free Care Improve Adults' Health? Results from a Controlled Trial of Cost Sharing in Health Insurance," N Engl J Med, December 8, 1983, 309, pp. 1426-1434.
Worth a fairly careful read.
• Shapiro, M.F., Ware, J.F., Sherbourne, C.D., "Effects of Cost Sharing on Seeking Care for Serious and Minor Symptoms," Annals of Internal Medicine, February 1986, 104, pp. 246-251.
Read quickly for the main ideas.
• Rasell, M.E., "Cost Sharing in Health Insurance -- A Reexamination," N Engl J Med, April 27, 1995, 332(17), pp. 1164-1168.
This article and the Gladwell pieces from the web argue against cost sharing as a cost control strategy.

• The Moral-Hazard Myth, by Malcolm Gladwell, The New Yorker, August 29, 2005.
• Malcolm Gladwell, interviewed about "The Moral-Hazard Myth" on the Al Franken Show, August 25, 2005: A 19-minute mp3.
• Gladwell said that the reason we don't have universal health insurance is that our leaders think that we're better off without it. Listen carefully to then-President Bush's "objective" for our health care system, from July 2007. It's in the first 20 seconds of the clip.
• Mark Pauly, "The Truth about Moral Hazard and Adverse Selection," Maxwell School of Syracuse University Policy Brief No. 36/2007. Mr. Moral Hazard replies.

• Wennberg, J.E., McPherson, K., Caper, P., "Will Payment Based on Diagnosis-Related Groups Control Hospital Costs?" N Engl J Med, August 2, 1984, 311, pp. 295-300. People living in different areas get very different care. This article created a whole area of health services research.

• Atul Gawande, The Cost Conundrum: What a Texas Town Can Teach Us about Health Care, The New Yorker, June 1, 2009. President Obama had all his policy people read this.
• The Dartmouth Atlas, http://www.dartmouthatlas.org/, has extensive data and analysis on medical practice variation. Two 2005 reports of interest are about Underuse of Effective Care and Misuse of Preference-Sensitive Care.

• Price and output under competition
• Price and output under monopoly

• Roe, B.B., "The UCR Boondoggle: A Death Knell for Private Practice?" N Engl J Med, July 2, 1981, 305(1), pp. 41-45. Pricing in health care didn't follow the competitive market model ...

• DRG and RBRVS Lecture notes

• Simborg, D.W., "DRG Creep: A New Hospital-Acquired Disease," N Engl J Med, June 25, 1981, 304(26), pp. 1602-1604.
• Baker, S.L., Kronenfeld, J.J., "Medicaid Prospective Payment: Case-Mix Increase," Health Care Financing Review, Fall 1990, 12(1), pp. 63-70.

• Hsiao, W.C., Braun, P., Dunn, D., Becker, E.R., DeNicola, M., Ketcham, T.R., "Results and Policy Implications of the Resource-Based Relative-Value Study," N Engl J Med, September 29, 1988, 319(13), pp. 881-888.
• Hsiao, W.C., Braun, P., Yntema, D., Becker, E.R., "Estimating Physicians' Work for a Resource-Based Relative Value Scale," N Engl J Med, September 29, 1988, 319(13), pp. 835-841.

• Reinhardt, U.E., "Resource Allocation in Health Care: The Allocation of Lifestyles to Providers," The Milbank Quarterly, 1987, 65(2), pp. 153-176.
• Brown, M.L., Kessler, L.G., Reuter, F.G., "Is the Supply of Mammography Machines Outstripping Need and Demand?" Annals of Internal Medicine, October, 1, 1990, 113(7), pp. 547-552. Also contrary to the competitive market model, excess capacity does not lead to price competition.
• Hillman, B.J., Joseph, C.A., Mabry, M.R., Sunshine, J.H., Kennedy, S.D., Noether, M., "Frequency and Costs of Diagnostic Imaging in Office Practice -- A Comparison of Self-Referring and Radiologist-Referring Physicians," N Engl J Med, Dec. 6, 1990, 323(23), pp. 1604-1608.
• Pattison, R.V., and Katz, H.M., "Investor-Owned and Not-for-Profit Hospitals: A Comparison Based on California Data," N Engl J Med, August 11, 1983, 309, pp. 347-353. More differences with the competitive model: Some providers (for-profit hospitals, in this case) can charge more than other providers for the same services.
• Woolhandler, S., Himmelstein, D.U., "Costs of Care and Administration at For-Profit and Other Hospitals in the United States," N Engl J Med, March 13, 1997, 336(11), pp. 769-74.
• Reinhardt, Uwe E., "The Pricing Of U.S. Hospital Services: Chaos Behind A Veil Of Secrecy," Health Affairs, January/February 2006; 25(1): 57-69.

• Is Medicare Raising Prices for the Privately Insured? Uwe Reinhardt, Oct. 16, 2009.
• Because the Blackboard readings for this class were not ready in time, I assigned a recent (2009) article from Wennberg's Dartmouth Medical School team about Medicare geographic cost variation.

• Himmelstein, D.U., Woolhandler, S., "Cost Without Benefit: Administrative Waste in U.S. Health Care," N Engl J Med, February 13, 1986, 314, pp. 441-445. Letters and authors' rejoinder, N Engl J Med, October 16, 1986, 315, pp. 1033-1035.
• Grumet, G.W., "Health Care Rationing Through Inconvenience: The Third Party's Secret Weapon," N Engl J Med, August 31, 1989, 321(9), pp. 607-611.
• Woolhandler, S., Himmelstein, D.U., "The Deteriorating Administrative Efficiency of the U.S. Health Care System," N Engl J Med, May 2, 1991, 324(18), pp. 1253-1258.

• Woolhandler, Campbell, and Himmelstein, Administrative cost update 2003.
• California HMOs reject one-fifth of submitted bills.

Canada slideshow and It's the Prices, Stupid, moved ahead two weeks.

• Needleman, J., Buerhaus, P., Mattke, S., Stewart, M., Zelevinsky, K., "Nurse-Staffing Levels and the Quality of Care in Hospitals," N Engl J Med, May 30, 2002, 346(22), pp. 1715-1722. An example of quality variation that the market does not solve. Read for the main ideas.

• The Institute of Medicine's Quality Chasm series. Glance at the PDF's of a couple of these. The first one, with the eye-popping estimate of the extent of error is at http://iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf
• An estimate of lives lost due to medical error.
• U.S. hospitals have to be pressured to adopt proven infection-control methods. What wasn't market competition enough?
• The Sept. 23, 2007, New York Times featured an article about quality falling dramatically at some nursing homes after they were bought by investment companies. What happened to the market? Why didn't the patients all switch to competing nursing homes that offered better quality for the money?

• Brennan, T.A., Sox, C.M., Burstin, H.R., "Relation Between Negligent Adverse Events and the Outcomes of Medical-Malpractice Litigation," N Engl J Med, December 26, 1996, 335(26), pp. 1963-1967. The skinny: There is not much relationship.
• Studdert, D.M., Mello, M.M., Gawande, A.A., Gandhi, T.K., Kachalia, A., Yoon, C., Puopolo, A.L., Brennan, T.A., "Claims, Errors, and Compensation payments in Medical Malpractice Litigation," N Engl J Med, May 11, 2006, Vol. 354, No. 18, pp. 2024-2033.
• Annas, G.J., "The Patient's Right to Safety -- Improving the Quality of Care through Litigation against Hospitals," N Engl J Med, May 11, 2006, Vol. 354, No. 19, pp. 2063-2066. In a market system, the consumer's power over the seller is the power to refuse to buy. That may be enough to guarantee quality of soap, for example. Do we need more than that for health care quality?

• Frivolous malpractice suits are a small portion of all suits.
• The business cycle determines malpractice insurance premiums.
Also:
• Public Citizen's Congress Watch, The 0.6 Percent Boogeyman, July 1, 2009. Medical malpractice tort costs have been falling (inflation-adjusted), and are down to 6/1000th of national health spending.

Economics of politics

• Political contributions by health care providers and insurers

• Mayer, T.R., and Mayer, G.G., "HMOs: Origins and Development" N Engl J Med, February 28, 1985, 312, pp. 590-594.
• Siu, A.L., Leibowitz, L., Brook, R.H., Goldman, N.S., Lurie, N., Newhouse, J.P., "Use of the Hospital in a Randomized Trial of Prepaid Care," JAMA, March 4, 1988, 259, pp. 1343-1346.
• Bodenheimer, T.S., and Grumbach, K., "Capitation or Decapitation," JAMA, October 2, 1996, 276(13), pp. 1025-1031.
• Morgan, R.O., Virnig, B.A., DeVito, C.A., Persily, N.A., "The Medicare-HMO Revolving Door -- The Healthy Go In and the Sick Go Out," N Engl J Med, July 17, 1997, 337(3), pp. 169-175.

• Sicko, a film by Michael Moore, 2007. The DVD is available for $10 or less at Amazon.com. A low-resolution multi-part version is on YouTube. A link to part 1..
For some of the media storm around Sicko:
• Blue Cross braces against Michael Moore's Sicko
• CNN's "Reality Check" of Sicko Why Sanjay Gupta didn't get nominated to be Surgeon General
• Michael Moore responds and on Moore's website
• Follow-up on Larry King's show
• Michael Moore on Chris Matthews Hardball, July 23, 2007
• Tu, H. T., Rising Health Costs, Medical Debt and Chronic Conditions Center for Studying Health System Change, Issue Brief No. 88, September 2004.
• Himmelstein DU, Warren E, Thorne D, Woolhandler S., "Illness and Injury as Contributors to Bankruptcy," Health Affairs, 2005 Jan-Jun, 2005, Supplement Web Exclusives, pp. W5-73.
• A Wal-Mart executive's memo proposing that they "dissuade unhealthy people from coming to work at Wal-Mart" by increasing health insurance copayments and making all jobs physically demanding, Nov. 2005.
• A woman's being beaten by her husband is a pre-existing condition in some states and D.C.
• A Caesarian section delivery is a pre-existing condition.
• Dick Cheney Loses His Health Insurance, The Onion, September 7, 2005, 41•36. The Onion is satire.
• A July 2002 www.kaisernetwork.org report on underinsurance.
• The 2009 Kaiser Family Foundation report on employer health benefits.
• A distinction between managed care and "real HMOs"?
• People pay for health insurance, then Blue Cross (of California) revokes it when they get sick. This illustrates, in an extreme way, the lack of consumer sovereignty in the health insurance market, which compounds the problem of lack of consumer sovereignty in health care markets. Here's the story, from the L.A. Times.
• How Much Money Do Health Insurance Companies Make? Uwe Reinhardt, Sept. 25, 2009
• What Portion of Premiums Should Insurers Pay Out in Benefits? Uwe Reinhardt Oct. 2, 2009
• The following report is now available only to ACP members: No Health Insurance? It's Enough to Make You Sick, American College of Physicians-American Society of Internal Medicine, 2000. The Report and the References are in separate files.
• Instead, go to the summary page for the Institute of Medicine's 2009 report, America's Uninsured Crisis: Consequences for Health and Health Care. Read the Testimony to Congress or the Report Brief.
• http://www.kff.org/uninsured/upload/7806-03.pdf is a source for similar ideas.
• Census Web Page with link for Income, Poverty, and Health Insurance Coverage in the United States, Census Bureau statistics on the number of insured and uninsured.
• Comparing measures of the number of uninsured

• Marcia Angell, "The Truth About the Drug Companies," New York Review of Books, Volume 51, Number 12, July 15, 2004 Read for the main ideas.
• Marcia Angell, "Your Dangerous Drugstore," New York Review of Books, Volume 53, Number 10, June 8, 2006 Read for the main ideas. What is Dr. Angell's complaint? Price? Quality? Lack of innovation? More than one of the above?
• Marcia Angell, "Drug Companies and Doctors: A Story of Corruption," New York Review of Books, January 15, 2009.
• Malcom Gladwell, "High Prices How to think about prescription drugs," The New Yorker, October 25, 2004. Answers Angell. Does he blame consumers for high drug spending?
• National Institute for Health Care Management Research and Educational Foundation, Prescription Drugs and Intellectual Property Protection Finding the Right Balance Between Access and Innovation, July 24, 2000. Available at: http://www.nihcm.org/pdf/prescription.pdf Read quickly for the main idea, which is illustrated in Figure 1.
• NPR report on Parke-Davis allegedly promoted Neurontin for uses not approved by the FDA, from June 2002. Follow-up reports: Oct. 2002, Nov. 2002, Dec. 2002, Jan. 2003. May 2004: Pfizer (which had acquired Parke-Davis) pled guilty and agreed to pay fines totalling $430 million. The report includes details of the marketing effort by a participating doctor. Worth a listen.
• NPR All Things Considered report on conflict of interest in pharmaceutical benefits management, August 22, 2003. Worth a listen.
• Pharmaceuticals' political contributions Before you glance at this, guess which party gets the most from the drug industry. You can also get the contributions breakdown for others industries and groups. Check out nurses' contributions.
• Riding The Rollercoaster: The Ups And Downs In Out-Of-Pocket Spending Under The Standard Medicare Drug Benefit, by Bruce Stuart, Becky A. Briesacher, Dennis G. Shea, Barbara Cooper, Fatima S. Baysac and M. Rhona Limcangco, in Health Affairs, 2005, Vol 24, Issue 4, 1022-1031.
• A British Medical Journal article argues that countries (like Britain) that negotiate lower drug prices are not free riders benefitting from U.S.-consumer-financed industry research without paying for it.

• The Kaiser Family Foundation's web page on the U.S. health care reform. Specifically,
  • A cute video: http://healthreform.kff.org/the-basics.aspx
  • A slideshow: http://www.kaiseredu.org/Tutorials-and-Presentations/A_I/Health-Reform-Overview.aspx
  • A paper: http://www.kff.org/healthreform/upload/8023-R.pdf
  • Medicaid is a big part of the health insurance expansion. http://www.kaiseredu.org/Tutorials-and-Presentations/A_I/Health-Reform-How-Will-Medicaid-Change.aspx
• Peter R. Orszag and Ezekiel J. Emanuel "Health Care Reform and Cost Control," New Engl J Med, June 16, 2010.

• Canada-US comparison slide show (671Kb)
• It's The Prices, Stupid: Why The United States Is So Different From Other Countries by Gerard F. Anderson, Uwe E. Reinhardt, Peter S. Hussey, and Varduhi Petrosyan . Higher health spending but lower use of health services adds up to much higher prices in the United States than in any other OECD country.
• David Blumenthal and William Hsiao, Privatization and Its Discontents — The Evolving Chinese Health Care System, New Engl J Med, Sept. 15, 2005.
• Bill Hsiao interviewed about the Taiwan health insurance system, which he helped design.
• In Canada, lower income people access primary care doctors just as much as higher income people. Education is positively related to utilization of specialists. There is no relationship between income and use of specialists in Canada, separate from education.
• "T.R. Reid: Looking Overseas For 'Healing Of America'". The page has a link to his Washington Post article. Reid's book, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care gives even more insight into health care system alternatives around the world, and is fun to read.
• Paul Krugman gives the 700-word version in "The Swiss Menace," by Paul Krugman, New York Times, August 16, 2009.

• Arnst, C., "The Best Medical Care In The U.S., How Veterans Affairs transformed itself -- and what it means for the rest of us," Business Week, July 17, 2006. To find this article, go to www.businessweek.com and type "The Best Medical Care In The U.S." in the search box. Then look down the list for this July 2006 article. For a more academic treatment, see Jonathan B. Perlin, Robert M. Kolodner, and Robert H. Roswell, "The Veterans Health Administration: Quality, Value, Accountability, and Information as Transforming Strategies for Patient-Centered Care," The American Journal of Managed Care, November 2004, pp. 828-836.
• A Time magazine article about the V.A.
• Lately, the VHA has been stretched.

• Newhouse, Joseph P., "Assessing Health Reform's Impact on Four Key Groups of Americans, Health Affairs 29:9, September 2010, pp. 1714-1725.
• Williams, David R., Mark B. McClellan, and Alice M. Rivlin, "Beyond The Affordable Care Act: Achieving Real Improvements In Americans' Health," Health Affairs 29:8, August 2010, pp. 1481-1488.

Primary Care Reform

• Howell, Joel D., "Reflections on the Past and Future of Primary Care" Health Affairs 29:5, May 2010, pp. 760-765.
• Friedberg, Mark W., Peter S. Hussey, and Eric C. Schneider "Primary Care: A Critical Review of the Evidence on Quality and Costs of Health Care" Health Affairs 29:5, May 2010, pp. 766-772.
• David Margolius and Thomas Bodenheimer, "Transforming Primary Care: From Past Practice to the Practice of the Future" Health Affairs 29:5, May 2010, pp. 779-784.
• Bryan T. Vaughn, Steven R. DeVrieze, Shelby D. Reed, and Kevin A. Schulman "Can We Close The Income And Wealth Gap Between Specialists And Primary Care Physicians?" Health Affairs 29:5, May 2010, pp. 933-940.
• Jack M. Colwill "A Case of 'Medical Homelessness'" Health Affairs 29:5, May 2010, pp. 1067-1070.

Please see the News at the top of this syllabus for two items about the politics of health reform.

Nurses -- especially Advanced Practice Registered Nurses -- will be key to enabling the "world's best health care" system to actually care for the population.

• Pauline Chen," Nurses’ Role in the Future of Health Care," New York Times, November 18, 2010.
• For further reading skimming, if you are interested, The Future of Nursing, National Academy Press, 2010. This page allows you to view a pre-publication version.

More medical practices are owned by hospitals than by doctors, according to one survey.