Unanticipated Consequences in Health Policy: The Sequelae of Franka, Bates, and the Patient Protection and Affordable Care Act

The Constitution of The United States, in Article 1, Section 8, specifically authorizes Congress to “…provide for the general welfare of the United States....” While this section of the Constitution has never been interpreted as requiring our government to provide individual medical care for our citizens, there has been a long history of initiatives to provide for at least some medical services. The most successful initiative was the passage of Medicare in 1965, and subsequent attempts to expand the program have been largely unsuccessful. President Obama was able to seize a moment of political urgency to create a coalition that ultimately allowed passage of the controversial Patient Protection and Affordable Care Act (ACA) of 2010. This initiative still is creating havoc among health care consumers, providers, payers and politicians. Social and public health problems related to how we provide, finance, ration, and regulate healthcare in the United States are part of our open and daily discourse as to why we continue to have a myriad of problems related to the healthcare industry. Health care remains expensive, access is compromised, and individual contributions in the form of patient co-payments and deductibles have increased to the point where medical care is compromised. Recent legislative initiatives were never intended to create the problems we are now experiencing; these problems exist both because of the paths we have previously taken, and because parts of our legislation have allowed or fostered unanticipated consequences. ^ This dissertation explores three cases of how the unanticipated consequences of various initiatives have affected how we provide or how we finance healthcare in the U.S. The cases look at changes and consequences of tort reform (Franka), the effects expanding commercialism that came about as a result of increased marketing of healthcare goods and services (Bates) and how both foreseeable and unforeseeable consequences of the ACA have altered virtually every aspect of healthcare in the U.S. While it is hoped that the next group of legislative efforts will evolve to resolve rather than perpetuate impediments to optimal, affordable, and evidence-based effective healthcare in this country, unforeseeable consequences will undoubtedly arise just as they have arisen in the past. The three cases that comprise this dissertation (and the three separable papers therein) explore the contribution of recent legislative initiatives that have, to a large extent, resulted in our having the world’s most expensive and inefficient healthcare system.