Health Policy and the Affordable Care Act

Ezekiel J. Emanuel, University of Pennsylvania

This course will explore the many problems of the American health care system and discuss the specific ways that the Affordable Care Act will impact access, quality, costs, as well as medical innovation.

The American health care system has many problems. 50 million people are uninsured. Quality is extremely uneven, with peaks of greatness at leading academic centers but overall poor quality in both process measures and outcomes such as asthma deaths. Finally, the U.S. health care system spends over $8000 per patient per year, nearly double the next highest country. In March 2010, the Affordable Care Act was enacted. Over the next decade or more, the Act will dramatically re-structure the American health care system.

This course will explore the history and structure of the current American health care system, including the history of and problems with employment-based health insurance, the challenges surrounding access, cost and quality, and the medical malpractice conundrum. The course will then explore the history of health care reform and the challenges that were overcome to achieve health reform in America. Finally, we will delineate the specific ways that the Affordable Care Act improves access and quality, and will control costs. Throughout lessons regarding health economics, health policy, and medical practice will be elucidated.

This class is open to anyone that is interested in gaining a better understanding of the US health care system and the challenges of health care reform. There are no prerequisites or required knowledge of the health system.


Week 1 – Growth in US Health Care
Much of the impetus for health care reform is provided by the need to “bend the cost curve.”  Over the past few decades, health care cost growth has consistently outpaced overall economic growth, taking up an increasing share of our Gross Domestic Product (GDP) and government budgets.  We will discuss the factors that drive cost growth.

Live Q & A with Dr. Emanuel
Dr. Emanuel will host a live online Q & A session on topics related to health care and current events.

Week 2 – Structure of the US Health Care
How do Americans get their health care? Who pays for it? How did the system we have today come to be?  These are some of the questions we will answer this week when we look at the structure of the US health care system

Week 3 – Access to and Quality of Health Care in the US
Most Americans receive insurance through their employer or the government (e.g. Medicaid, Medicare, CHIP).  Before the ACA, approximately 50 million Americans did not have health insurance. This week we explore access to health care insurance, the profile of the average uninsured person, disparities in quality and outcomes, and the link between insurance and access to health care.

Week 4 – Health Care Malpractice
In some physician specialties, as many as one in four practitioners a year have a medical malpractice claim filed against them, making this a matter of frequent public and policy debate. We will discuss medical errors, the workings of the malpractice system, liability insurance, and the contribution of negligence and malpractice costs to the health system’s overall bottom line. 

Week 5 – History of health care reform; The ACA: An Overview
Health care reform in America has been 100 years in the making, starting with Theodore Roosevelt and continuing through the Clinton administration. We discuss past attempts at health care reform and why they met with resistance. We then move on to an overview of the 2010 Affordable Care Act.

Week 6 - The ACA: Access to Health Care
The overview of the ACA continues with a discussion of the provisions designed to expand access to health care.  We will cover employer-sponsored health insurance provisions. This session will feature a guest lecture by J. Sanford Schwartz, M.D.

Week 7 – The ACA: Cost Control
This week we will discuss projections of health care cost growth under the ACA, followed by mechanisms through which the ACA aims to tackle health care cost growth.

Week 8 – The ACA: Health Care Delivery and Quality
The final topic of the course is the ACA’s impact on the quality and delivery of care. The ACA includes provisions for institutional innovations, i.e. changes in how the system delivers care.  It also contains rules and incentives for providers to cut down on mistakes and deliver proven, valuable care. This week will provide a forward-looking overview of what we will change in the medical sector.

Recommended Background

No background is required; all are welcome.

Suggested Readings

Below are the readings for each week. Students should read the materials in their entirety unless a subset of pages is indicated. Where page ranges are indicated, they are inclusive, and students should begin and end reading at section breaks in the text. Please note all page numbers refer to the printed pages of the article, not the page number in your pdf reader, if applicable.

Abbreviations used:

Kaiser Foundation = The Henry J. Kaiser Family Foundation

RWJ Foundation = Robert Wood Johnson Foundation

CBO = Congressional Budget Office

Week 1 - Growth in US Health Care Costs

Optional: Additional Readings

Week 2 – Structure of the US Health Care System

Week 3 - Access to and Quality of Health Care



  • Elizabeth Docteur & Robert Berenson, How Does the Quality of US Health Care Compare Internationally?, The Urban Institute (August 2009), available at
  • GapMinder World (2012). Find the US on the following graphs by hovering over the circles and compare its performance to other OECD countries (in light green): infant mortality (, life expectancy ( Play with the indicators that interest you.

Optional: Additional Readings

Week 4 - Health Care Malpractice

Optional: Additional Readings

Week 5 - History of health care reform; The ACA: An Overview

Optional: Additional Readings

Week 6 - The ACA: Access to Health Care

Optional: Additional Readings

Week 7 - The ACA: Cost Control

Optional: Additional Readings

Week 8 - The ACA: Health Care Delivery and Quality

Optional: Additional Readings

Course Format

This class is eight weeks long. Each week, students will watch approximately 30 - 40 minutes of lectures delivered by Dr. Emanuel. Students should expect to spend 2 - 5 hours per week reading related materials from the reading list, all of which are freely accessible online.

Students taking the course for a grade will complete one short essay question (approximately 1 page) per week, which will be peer-graded based on a detailed answer key provided after the due date. Of the eight scores earned for assignments, the lowest two scores will be dropped in calculating the final grade. The remaining six scores will be weighted equally. As a result, students who miss a homework assignment can still earn full credit in the course. There are no exams or final projects in this course. Students not taking the course for a grade may choose not to complete the assignments.

The details of these logistics are subject to change; if changes are made, students will be notified via an announcement and this page will be updated.



  • Will this content be available after the course is over?
    Yes, we intend to maintain this information online.
  • Will I receive college credit for this course?
    Coursera and the University of Pennsylvania do not provide college credit for this course, however, students who satisfactorily complete the course requirements will receive a certificate of completion.
  • How many students are in this class?
    This information reaches a large number of people.  In the summer of 2012, 17,246 people were signed up to take the course on the first week of lectures and 31,967 people were registered by end of the course.  However, of those students, 3,428 submitted the first assignment and 1,066 submitted the final assignment.  1,340 people completed at least five assignments and 1,023 people passed the course.  While there is more attrition than in a traditional classroom, this is in part due to the online, free aspect of the course as people may sign up who are curious, but are not interested in completing the course.  This course offers significant flexibility for students in terms of not only when you do the work, but also how much you complete.  Some students wish to learn as much as possible about the topic while others are interested in learning only a portion of the material.  Students complete the work because they are genuinely interested in learning the material.
  • I joined the class late.  Can I still participate?
    The top 6 of 8 assignments are calculated for your grade.  Thus you may miss 2 assignments without impacting your grade.  Even if you joined too late to pass the course, you may participate in the class at any point by watching the videos, reading the material, and participating in the forums.


  • Why did you select these readings?
    The readings are limited to those which are freely available to the public, to facilitate anyone participating in the course.  Students widely range in their background and health care experience.  Thus, while the selected readings are generally at college level, they assume a student will have only a basic understanding of the American health care system.  Additional optional readings are provided for those who wish to delve deeper into a particular topic.
  • Why do you have optional readings?
    Some people may be interesting in learning more about a topic.  For those students, we have identified optional readings.  These optional readings provide background material or more in-depth information on a topic.  You will be graded only on information in the required readings.


  • I can’t complete an assignment.  Will I fail?
    The top 6 of 8 assignments are calculated for your grade.  Thus you may miss 2 assignments without impacting your grade. 
  • How will I be graded?
    You are given one assignment each week.  The top 6 of 8 assignments are calculated for your grade.  Thus you may miss 2 assignments without impacting your grade.  For each assignment, you will be graded by a minimum of four other people.  The high and low score for each assignment will be tossed out and the other scores averaged.
  • Am I required to participate in the forums?  Are the quizzes graded?
    Participation in the forums and quizzes available through the video content are not graded.
  • How will I grade others?
    Reviewers will receive a grading rubric and sample answer.
  • How will you ensure that the grades are fair?
    We expect students are motivated to participate in their education and we ask that everyone grade each other in an objective, fair, and unbiased manner.  Grading will be double-blind; graders will not know whose work they are grading, and students will not know who graded their work.  Each assignment is graded by several different people, which will reduce any potential bias, with the high and low scores dropped for each student.  Furthermore, the selection of assignments to grade for each person will be random each week, so any given student is unlikely to have his/her work graded by any given student grader more than once.  Finally, we will be checking the grading for consistency (e.g. by comparing against grades assigned by the instructor to a few "sample" assignments).
  • Why do you require students to grade each other?
    This course is freely available on the internet.  During the summer 2012 course, 31, 967 students signed up for the course.  Coursera and the University of Pennsylvania are not able to support providing this course free for everyone without utilizing innovative and non-traditional grading mechanisms.  We also believe that in grading each other, you will learn the material better.
  • What happens if I grade more assignments one week than the minimum required?  Will I get extra credit?
    You will receive the appreciation of your classmates and hopefully a greater understanding of the material.  You will not, however, receive any extra credit.
  • Can I grade extra assignments one week to make up for grading fewer assignments another week?
    No.  You are required to grade a minimum of five assignments each week.


  • Please provide a spell-check option.
    Until Coursera is able to provide this option, we suggest that you draft your answer in Word, spell-check it, and then copy and paste your answer into the answer box.
  • How do I copy my answer into the assignment submission box?  It does not work.
    This is possibly a browser issue; Coursera is optimized for Google Chrome.  Try using the command keys to copy and paste your answer from Word: Ctrl-A (highlight all), Ctrl-C (copy), and Ctrl-V (paste).
  • How do you close the window for the multiple-choice question to resume the lecture video after the quizzes pop up?
    This is possibly a browser issue.  Coursera supports modern web standards and the many devices that run browsers that support these features.  Chrome, Firefox, IE (9-10), and Safari meet these requirements. 

For more information about Penn’s Online Learning Initiative, please go to:

  • 25 March 2013, 8 weeks
  • 25 June 2012, 8 weeks
Course properties:
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  • Language: English Gb


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