Implementing American Health Care Reform: The Fiduciary Imperative

The Patient Protection and Affordable Care Act fundamentally restructures America's health care system, creating new entities and obligations with little statutory guidance for implementation. Matthew argues that fiduciary law—grounded in agency theory and common law principles—provides essential organizational frameworks for health care reform implementation. All health care actors, including the state, create, finance, and distribute health care within fiduciary relationships with patients. Matthew challenges two misconceptions: that one-size fiduciary law fits all relationships, and that medical relationships are fiduciary merely because parties are trusts. Most health care relationships are indeed fiduciary, requiring legal paradigms extending established fiduciary duties from physician-patient relationships to institutional health care providers and public payers. The article examines how fiduciary medicine model applies four principles sharpening fiduciary rules: addressing financial conflicts of interest, clarifying informed consent, reforming consent law, and proposing legislative enactment. Matthew demonstrates that fiduciary law frameworks govern health care actors' creation, finance, and distribution of health care. Without such frameworks, implementation of America's health care reform could fall short of Congress's goal to universalize health access while reshaping markets that finance and deliver care. The fiduciary medicine model guides legislators, regulators, and courts in achieving reform goals.

Topics: Administrative Law · Constitutional Law · Contracts

Keywords: health care reform · fiduciary law · Affordable Care Act · physician-patient relationship · fiduciary duties · informed consent · health care implementation