Rising Costs of Health Care

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					                      Teaching Strategies/Activities
                                  Sample Lesson Plan
                                   Nursing Services
                                         CIP # 51.1600

                                Rising Costs of Health Care

Source: Adapted from a lesson for the PBS program Now with Bill Moyers by:
Donna DeTommaso-Kleinert
North Penn School District
Lansdale, Pa.

ADE CTE Nursing Services Competencies/Indicators addressed:

Level: 9 - 12

Estimated Time for Activity: 2 to 4 class periods

Materials Required:
Bill Moyers' May 17, 2002 story, "As Goes Maine" (attached to this file)
Worksheets (Attached at the end of this file):
      What is Health Insurance?
      KWL Rising Costs of Health Care chart
      Who is Affected and How
      Role Play
      Assessment Rubric
Internet access, or copies of relevant pages
TV/VCR (optional)

Instructor Section:

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Overview of Activity:
The health care system in the United States has gone through many changes and revisions
over the past years. It is often a political topic in election years and influences how some people
vote. Changes in health care have brought cost increases, adjustments in care, and an enlarged
divide between those who have adequate insurance and those who do not. The rise in health
care costs has had a different impact on a variety of populations, health care professionals and
the health care industry.

To illustrate these conditions, this lesson uses the 'NOW with Bill Moyers' May 17, 2002 story,
"As Goes Maine" as a tool. Watching the story and follow-up interview or reading the transcripts
provides a comprehensive overview of the effects of rising health care costs on many different
people, types of health care, and businesses in the city of Portland, Maine.

In examining the health care system, also consider proposed changes by President George W.
Bush that are intended to fill gaps in the system and make health care affordable to all. An
overview of President's Bush's Health Care Plan can be located at

Learning Objectives
After completing this activity, the student will be able to:
 Evaluate a person's point of view on the rising costs of health care and identify the impact of
    rising costs on one's employment and personal life.
 Interpret multiple perspectives related to the causes of rising health care costs and how
    increases affect different populations, positions and industries.
 Formulate a solution to the rising costs of health care.
 Write a persuasive letter to a newspaper editor, public official or organization proposing
    ways to control health care costs in the U.S.
 Work collaboratively with a partner.

Teaching Strategy

1. An anticipatory set for this lesson could include bringing in empty prescription bottles of
   typical medications that students might have taken such as penicillin, asthma medication, or
   prescription anti-inflammatory drugs. Place the bottles on a table where the students can
   see them and have students guess the actual cost of the drugs without health insurance, if it
   is a generic drug and what it would cost with health insurance such as an HMO. (Costs can
   often be determined from prescription receipts, insurance statements or salespeople, or a
   pharmacist. Or hand out a copy of an actual bill from a common surgery. Show students the
   difference in actual costs and costs covered by several health care plans. Lead into the next
   activity with the students thinking about the following essential questions: "Why are health
   care costs rising?" "How are different professions, people and industries affected by the cost
   of health care in the United States?"

2. Working in Think/Pair/Share partnerships, have students use the Health Association of
   America Web site ( to reference their
   Consumer Guide to Health Insurance. (Alternatively, the guide could be downloaded in
   advance and a copy made for each partnership.) Have students work with their partners to

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   complete the 'What is Health Insurance?' concept map (See below). This activity will help
   students acquire the necessary background information about different types of health care,
   as well as important health care vocabulary.

3. After completing the concept map, have students work with their partners to complete the K-
   W-L chart related to "The Rising Costs of Health Care." (See Below)

4. Have groups share out the concept maps and K-W-L charts. The students at this point
   should have a basic understanding of health insurance and have drawn on prior knowledge
   related to the rise in health care costs by completing the K-W-L chart. You may wish to also
   briefly discuss additional background information on the need for medical research,
   improved technology, high costs of malpractice insurance, and the stringent regulations of
   the Food and Drug Administration.

5. Using the Internet or printed handouts, have students individually read the "As Goes Maine"
   transcript from the May 17, 2002 'NOW with Bill Moyers' broadcast (See below). This
   reading could be potentially assigned for homework. (Alternatively, the video could be
   shown in class. Programs can be taped off-air and used in the classroom for one year, or
   purchased from ShopPBS.)

6. After reading the transcript or watching the video, have students brainstorm answers to the
   question "Who is affected by the rise in health care costs?" Use the worksheet titled, "The
   Rising Costs of Health Care - Who is Affected and How" (See below) to capture their
   thinking. Encourage them to come at the question from as many perspectives as possible.
   For example, what impact does it have on their families, families on welfare, families in high
   socio-economic areas, health care businesses and professionals such as hospitals and
   physicians, pharmaceutical companies, senior citizens, those using managed care plans, on
   Medicaid, etc. Once they have identified the section of the worksheet addressing "WHO",
   have them complete the section focusing on "HOW".

7. Review some of the lists with the class. Ideally, students have accurately identified some of
   the differences in how rising health care costs affect people without health insurance, small
   businesses, health care professionals etc.

8. Set up new Think/Pair/Share partnerships and assign each set of partners one role to take
   on such as doctor, nurse, lawyer, low socio-economic family, middle socio-economic family,
   high socio-economic family, a hospital CEO, a small business owner, a CEO of a large
   corporation, a health insurance agent, a nurse, pharmaceutical company worker, a
   pharmacist, senior citizen, and President Bush.

9. Distribute the Role Play worksheet (See below) and challenge students to reread (or re-
   watch) the "As Goes Maine" story through the eyes of their assigned role and answer the
   questions on the worksheet. The group that is representing President Bush should also read
   President Bush's Health Care Plan. Guide students to really delve into their role and focus
   in-depth on the details of how health care costs truly affect their lives, from their paychecks,
   to their budgets, to accessing the health care system.

10. Have each set of partners share how the person they represent is affected by rising health
    care costs and their three possible solutions to controlling costs. List the possible solutions
    and discuss how other roles would be impacted if the solutions were implemented.

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11. As a culminating activity, have students choose one of the roles shared (doesn't have to be
    their original role) and write a persuasive letter to a newspaper editor, public official or
    organization proposing ways to control health care costs in the U.S. They are to recommend
    solutions that directly impact the perspective they chose. For example, a student may
    choose to write through the eyes of a small business owner who is struggling to provide
    health care benefits to his or her employees. The letter would include ideas for how small
    business owners could offer affordable benefits packages to their employees, possibly
    including ideas for the U.S. government or the public at large. Letters can then be sent out
    to actual agencies, legislators etc.

12. Have students revisit their K-W-L chart and work with their K-W-L partner to complete the
    learned section of the chart.

Assessment Recommendations

   A rubric can be used for Think/Pair/Share partner work. A sample Think/Pair/Share rubric is
   Assess the clarity and completeness of student responses on the concept map and K-W-L
   Assess the persuasive letter for content, conventions, style and readability.
   Assess student presentations to the class for quality and content.

Extension Ideas

   Adapting the questions from the Role Play worksheet, students can interview health care
    professionals such as a pharmacist, doctor, nurse, hospital spokesperson, small business
    owner, large corporation benefits officer, etc.

   Invite a health care worker into the classroom and have him or her explain how his or her job
    has changed over the last several years due to the rise in health care costs.

   Have students visit the Department of Health Web site for the state in which they live. Ask
    students to research the estimated percentage of people in their state without health
    insurance and have them come up with reasons why that is happening in their state.

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                               Transcript: As Goes Maine
JULIE ROVNER: Portland, Maine is the urban center of this decidedly rural Northeastern state.
The motto here is "Vacation Land" because Maine is a magnet for tens of thousands of
summertime tourists.

But Maine is notable these days for more than its lobsters and lighthouses — this state in some
ways offers a glimpse of America's future: an older population, and an economy straining under
the momentous costs of medical care.

The shoemaking and canning industries that helped build this state dwindled years ago. Today
the state's economy is dominated by small businesses. Ninety percent of the companies here
have fewer than 20 employees.

LT's Incorporated typifies this state's economy. It's a screenprinting business in downtown

K.C. HUGHES, OWNER LT'S INCORPORATED: I think the apparel is really our biggest part of
the business.

ROVNER: How big a company are you?

K.C. HUGHES: We have 15 employees, most of the year, and during the summer we have as
many as 20.

ROVNER: LT'S is also emblematic of something else that distinguishes Maine — the crushing
cost of health insurance.

K.C. HUGHES: We've just seen just incredible rate increases. I think it was 12 percent, 12
percent, and then this year we're looking at a 38 percent increase.

Some companies around us have seen even bigger than 40 percent increases. So — you know
— how do you — how do you budget for that if you didn't know it was coming?

ROVNER: To hang onto the policy, Hughes has had to pass on some of these increases to his
employees. For a family, the cost is $800 a month, for an individual, it's $300. To many, these
costs are simply too much, and they've given up their coverage.

K.C. HUGHES: I know people that can't get insurance, they just can't get it — they can't afford
it. They're looking at a $1200 bill a month for health insurance cause they're an individual policy.
And I don't — I just can't imagine that. That's like another mortgage, it's an additional mortgage,
and how do people pay that?

ROVNER: Health insurance is now the company's third largest expense behind payroll and the
mortgage. The monthly bill is over $15,000.

K.C. HUGHES: I just don't even want to look at these numbers. It's just — it's death defying to
stay in business. I don't know how people do it. And it will come to a point where we have to just
draw the line and say, "We can't do it anymore." Unless something radically changes.

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ROVNER: Maine's the first state to see the sunrise every morning. Some say Maine could also
be the first state to see something far more ominous, a health insurance meltdown.

JAY HOUGHTON, NURSE, PORTLAND MAINE: The cost of medical care is skyrocketing
totally out of control. And that is the bottom line.

ROVNER: Jay Houghton is a nurse at Mercy Hospital in Portland, Maine. Every day, she sees
fresh evidence of a system in crisis.

JAY HOUGHTON: Nobody is happy where the situation is. Nobody is happy. I don't think the
insurance companies are happy with the situation. Certainly, the patients aren't, certainly the
doctors aren't. The hospitals are in dire straits.

Hi, can I take your blood pressure?

ROVNER: Dan and Carolyn Perkins know just how critical health insurance is.

CAROLYN PERKINS: I have an HMO. It's Anthem Blue Cross Blue Shield Maine Partners.

DAN PERKINS: We can't afford to be without insurance ... as expensive as it seems to be for
us-we're grateful that we do have it.

ROVNER: Carolyn's surgery today could easily run into the thousands of dollars. But as vital as
it is to them, the $300 monthly premium is straining the family's budget.

DAN PERKINS: I can't stand up and say no, I'm not going to pay my premium or I'm not going
to give you this money this week because I have to go grocery shopping. You know, that's--it's
not an option. We have no options. They say you pay this amount, and we have to pay that
amount. Or you will lose your insurance.

When you have no choice, you have no choice. But certainly everyone likes to have an option.
And right now our options seem very, very few.

JAY HOUGHTON: It's getting to be that really only rich people are going to be able to afford
health insurance. Now, Maine is not a rich state. We are a relatively poor state. And there's
really very few families that can afford that kind of money.

ROVNER: Maine's older population makes the state especially vulnerable to the spiking cost of
health care. The elderly need more of the medicine's big ticket items — prescription drugs, high
tech procedures, and long hospitalizations.

And Maine's small population — just over a million people — is spread across a state that the
rest of New England would fit into. That makes delivering health care here less efficient and
more costly.

Insurance companies find it hard to make a profit in this state, and many have already left.
Those that remain are constantly raising their premiums. But when rates go up, more people
drop out. These uninsured strain the system even more, which forces costs up yet again.

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JAY HOUGHTON; When you're uninsured you don't go to the doctor, and you go to the
emergency room. Now, if anybody's been to the emergency room you know it is the most
expensive form of healthcare there is. I had to go once many years ago just for something minor
and I--the bills were astronomical. They were astronomical.

ROVNER: Fed up with the current system, Houghton joined a grassroots group that put a
referendum on Portland's ballot asking the state to study what's called a single payer system -
it's very similar to what Canada does — everyone there is covered by the government, but it's
paid for through higher taxes.

JAY HOUGHTON: A single payer system would mean that all that money would go directly into
healthcare and not into administrative costs, not into lobbying, not into lawyers' fees, not into
physicians' groups or anything else. It would just go directly into paying the bills for healthcare.

ROVNER: It was a non-binding referendum...But that didn't stop major insurers from waging an
air war to squash it.

TELEVISION AD: There's gonna be less choice. What doctor am I gonna see? It's a horrible

ROVNER: Dozens of ads denounced the referendum as a recipe for higher taxes and restricted
access to doctors. Maine's biggest insurance company, Anthem Blue Cross Blue Shield, poured
almost $400,000 into the effort — outspending Houghton's group by almost 20-to-1.

TRISH RILEY: Ads started to come on TV opposing it. Largely supported by insurers and
others. And I think in Maine that didn't feel fair. The same insurers that were before the — the
rate setting mechanisms of the state to get premium increases, were having money available to
oppose a referendum that most people didn't even know was gonna be on the ballot. And I think
it just, Maine's a state where fairness matters. It's not fair that some people have to pay this
much for their health care and they didn't think that was fair.

ROVNER: Despite the intense campaign, the referendum passed - albeit by a very slim margin
— 52 to 48.

Maine probably can't implement a full-fledged single payer system even if it wanted to — a
federal law blocks states from regulating many employer health plans. But people here fully
expect the state will do something to ensure that every citizen who wants health insurance can
get it.

Maine's legislature has a feisty streak of health care activism — its latest cost control effort was
trying to force pharmaceutical companies to lower prices statewide — that foray landed them in
federal court.

But Maine has also become a symbol of the growing agitation in America over the state of our
healthcare system — and of the debate about how to best control the spiraling cost of medicine.

technology has given us capabilities within the health care field, you know, that three years, five
years ago, certainly ten years ago were unheard of and never thought of.

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ROVNER: Jim Parker is Vice President of Anthem Blue Cross, Blue Shield. He sees spiraling
costs as a real problem, but says they're the result of us getting just what we asked for: the best
that modern medicine has to offer.

JIM PARKER: The pharmaceutical industry has over 400 patents--400 prescriptions in the
patent pipeline, many of which, you know, hold great promise for--for those in need of them.
And so, we're in this awkward time in which we've created a — where we've painted a medical
opportunity that perhaps could be beyond society's stomach for paying for.

ROVNER: The undeniable benefits of this medical and pharmaceutical boom come with one
considerable drawback — nearly forty million Americans who can't afford to pay for them.

And so the debate in Maine really is the nation's debate — who's going to be responsible for
balancing what we want out of medicine with what we're willing to pay for?

can fix it — you know we'll cut this a little — we'll cut a position here -position there. And I'm
saying you know it just can't be done. That it is time for a drastic overhaul of the system.

ROVNER: Howard Buckley is a rather unlikely convert to government intervention in health
care. He's the President of Mercy Hospital, a registered Republican, and a forty-year veteran of
profit-driven healthcare. But he changed his mind when came to the conclusion that the
interests of business and the interests of medicine had become incompatible.

HOWARD BUCKLEY: If you're a managed care company, you make your money by denying
coverage to patients. If you do that, you make money. If you slow the payment process down,
you make money. The incentives are very perverse and certainly are not in the best interests of
the patient.

The whole concentration has been on the business aspects of providing care and not on what
the true calling was of providing a service to people who are sick and are in need.

JAY HOUGHTON: We believe that healthcare is a human right for the public good. Something
that touches everybody's lives, but that they cannot handle for themselves. For instance, our
public highway department, our public transportation, police and fire protection, Coast Guard,
that kind of thing--all of these things directly touch our lives, but we can't handle each on our

So, it can't be run like a business. Healthcare is not the same as an automobile or a computer.
And we really feel that the whole healthcare system has got to be removed from the

MARK CENCI, HEAD OF MAINE'S LIBERTARIAN PARTY: You can't say that market rules
like supply and demand have no bearing whatsoever on healthcare. The problem with a
universal healthcare system is that the demand is infinite. But the supply has got to be limited.

ROVNER: Geologist Mark Cenci is the head of Maine's Libertarian Party. He agrees the system
is broken, but rather than the government stepping in, he thinks that medicine needs more of
the discipline only the marketplace can provide.

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MARK CENCI: And rather than take health care completely away from market forces, which
would happen with a government-run program, tax-funded, we need to at least keep some
crucial market forces at play in health care markets.

PRESIDENT BUSH (FROM TAPE): So here's what I propose. I propose we give workers more
choice. I propose we reform the system-

ROVNER: This is the hot idea in Washington DC today — letting individuals spend their own
money in the medical marketplace.

PRESIDENT BUSH (FROM TAPE): To make the system more individualized, by creating
personal health accounts... ROVNER: Conservatives say if we really knew how much things
cost, we'd rein in our spending and force healthcare providers to lower their prices.

PRESIDENT BUSH (FROM TAPE): The money is your money. It's your money in the health
account, not the government's money. And you can use it for whatever health care need that
arises. If you don't use it, it's yours to keep.

ROVNER: The ideas are simple, if revolutionary. Instead of providing comprehensive insurance,
employers would provide workers with policies that cover only the most extraordinary costs —
and give them a set number of dollars to spend on more routine care.

MARK CENCI: I think that if you're — faced with a situation of where you, you are going to be
spending your own money and not assuming that everyone else is paying for your health care
needs, that you will become more of an active consumer — just like every other aspect of our
lives, be it a pur — car purchase or computer purchase or clothes or food — yes, you will be
more vigilant, and you will be looking for the best products at the best prices.

ROVNER: The goal is the same — make sure everyone can get the care they need. Policy
analyst — and Maine resident — Trish Riley says Mainers are fed up enough to do something

TRISH RILEY: I think people in Maine want universal coverage. We live in the shadow of
Canada. We certainly know the problems of access in Canada. But there's something that
seems right to people here. That because you live in a state, everybody should get access to
the same kind of health care.

ROVNER: Regardless of what reform measure you propose, everyone says they're in favor of
better, cheaper medicine for all Americans. But no one ever seems to reach agreement on a
foolproof way to fix the system.

TRISH RILEY: I think what's kept us all over the country from dealing with this issue isn't lack of
good ideas. It isn't lack of good people. It's lack of will. We're just afraid to make the
commitment 'cause it's big change and it's big money.

ROVNER: The real question is whether what's stirring in Maine is just a product of this state's
unique circumstances, or whether this debate will spread to the rest of the nation. If it does, then
we could face a return to the bruising fight that embroiled the country a decade ago.

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      What is Health Insurance?
      Concept Map                          What is Managed Care?

       What is Fee for Service?
                                                                               What are Self-Insured Plans?

Other forms of Health Insurance                                                How is “Appropriate Care”

                                            WHAT IS HEALTH

        What is Not Covered                                                      How do I get Insurance?
        by Insurance?
                                           What if Someone Has a
                                           “Pre-existing Condition?

 Directions Read through the consumer guide titled "Consumer Information -Health Insurance." Using
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 the concept map, summarize most important information pertaining to each topic in the space provided.
      November 2004
 Be prepared to share your answers with the class.
                     The Rising Costs of Health Care: KWL Chart

What Do We Already     What Do We Want to    What Did We Learn?   The Impact on Our
      Know?                  Learn?                                     Lives?

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            The Rising Costs of Health Care: Who is Affected and How?

 WHO is Affected by the rising costs of           HOW are they affected?
             health care?
     Example: Doctors/Physicians            Example: they need to raise the cost of
                                          treatments. They may prescribe treatment
                                           that the patients cannot afford. They pay
                                                      for more insurance.

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             Role Play: How The Rising Costs of Health Care Affect Me

Directions: Your assigned role is ___________________.
Read the "As Goes Maine…" transcript through the eyes of your assigned role and
answer the questions below.

1. Provide a brief character sketch, including a description of who you are, type of
employment, etc.

2. Summarize at least two ways your assigned role is affected by the rising costs of
health care?

3. If you could have a conversation with a person in your role make at least 3
predictions as to what you think would be their solution to controlling rising health care

4. One new thing I learned from this activity?

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                                 Think-Pair-Share Rubric

                         Novice         Practitioner        Proficient                Mastery
Contributed to     Little evidence of   Needed              Stayed on task      Stayed on task,
the partnership    cooperation.         prompting to stay   and cooperated      cooperated with
by following                            on task.            with partner.       partner and
directions,                                                                     demonstrated
staying on                                                                      leadership by
task and                                                                        assisting others
listening to                                                                    with cooperation
partner                                                                         and staying on

Completion         No work              Little effort and   Answers reflect     Responses are
of                 completed            minimal answers     basic information   complete.
worksheets                              and facts.          requested.          Answers reflect
                                        Responses on                            in-depth
                                        worksheet are                           thought and
                                        difficult to                            thinking outside
                                        understand.                             the box.
                                        Missed the key                          Detailed and
                                        points.                                 inferences

Presentation       Did not present      Minimal             Presented his or    Presented his
of assigned        to the class.        presentation        her portion to      or her portion
role                                    with little         the class.          to the class
                                        information                             using eye contact
                                        shared.                                 and good volume.

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