The Law of Unintended Consequences


The Patients’ Bill of Rights


This is something that we can all agree about.  I am going to describe an unintended consequence of the present legislation starting with its prehistory.


In the 1930s there was much controversy about socialized medicine.  A competent attempt at hospital insurance was floated under the name Blue Cross.  Only the name survives.  The actuaries and accountants who devised the original plan emphasized community rating in order to make the premiums affordable for the entire population with special concern for those with chronic diseases.  Community rating was to raise enough revenue from the healthy to cover the sick.  These pioneers thought of many other things, for instance lab and x-ray services were covered only in the hospital.  A patient could be a hospital patient for that purpose only.  This was because at that time, consistent quality control existed only for hospital laboratories and x-ray departments.  Blue Cross wanted to pay only for top quality services.


Along came wage and price controls during World War II.  Employers competed for scarce employees with fringe benefits especially health insurance because these were not included in the wage controls.  Later I heard from a labor executive that some labor leaders regretted pushing for health insurance at work because otherwise the government would have been compelled to provide it.


Health insurance as a fringe benefit at work was the beginning of “cherry picking” by insurance companies looking for the healthiest groups to insure thus enhancing profitability.  Blue Cross still exists in name.  Most if not all Blue Cross plans have gone commercial.


We all applaud the purpose of the Patients’ Bill of Rights, defending the public from arbitrary authority at HMO headquarters.  The unintended consequence is increasing numbers of part-time employees and employers opting out of health insurance entirely.  The percent of our population without health insurance is rising steadily.  The costs of an effective Patients’ Bill of Rights will accelerate the increasing proportion of our population that is uninsured or inadequately insured.


Another unintended consequence of fringe benefits at work is compulsory overtime with its health and social consequences.  I am referring to more stress and less family time but also to more unemployment.

It is cheaper for an employer to pay overtime to existing employees than to hire new help because of the increased expenditure for the new employees’ fringe benefits.


Unintended consequences creep into the best laid plans, the main reason for pilot programs for innovations.


John A. Frantz, MD, Chairman, Monroe Board of Health,  July24,2001


Social Medicine

The Improvement of medicine may eventually prolong life, but the improvement of social conditions can achieve this result more rapidly and more successfully.  Rudolf Virchow  1821-1902, founding father of cellular pathology and social medicine


Jimmy Carter is the only man who has used the presidency of the United States as a steppingstone to greatness.  This was spoken by the president of Emory University while introducing the ex-president.