Home / AHF Publications & Reports / The Drift

The Bureaucratization of the World

One prediction that's relatively safe to make about American health care in the foreseeable future - and about practically every other dimension of life in advanced "post-industrial" information societies - is that it will be increasingly regulated, controlled, and implemented in layers of administrative accountability.

Ironically, the more we integrate systems of care and apply the power of information technology to make the system more efficient and responsive, the greater this administrative and regulatory oversight will be.

One corollary of this trend is that lawyers and regulators, and not just physicians and other health care providers, will be major players when it comes to designing and directing the system in response to consumer demand.

A second corollary is that we will see more, not less, specialization in both professional and organizational configurations, which in turn will lead to even more regulation and public oversight.

Many people find this neither desirable nor inevitable. Political strategist Grover Norquist recently told a National Public Radio interviewer that the conservatives' primary mission was to "reduce the size of government by one-half over the next twenty-five years," which he considered to be a "serious and reasonable goal."

Norquist happened to say this right after a segment on the defection of Vermont senator James Jeffords from the Republican Party, and how Democrats were preparing to push through a patient's bill of rights and a prescription drug benefit for seniors.

But this isn't about liberal and conservative ideology, which always will wax and wane. It's about the sheer volume of demand for health care, the conflicts inherent in the tradeoffs between access, quality and cost; and the complexity of delivery and financing systems that are beyond the control of even those who profess to understand them.

Imagine you end up in conservative heaven, where everybody purchases health insurance and care in a free, unfettered market. In no time at all you get the political fallout of social justice issues, private individuals and for-profit organizations that seek redress for alleged slights and stacked decks, consumers screaming about invasion of privacy, and so on.

Or maybe you're in conservative hell, where everybody has access to universal health insurance financed through public dollars. Pretty soon you get charges of unfair rationing of care, private organizations shut out of the market, complaints about timely access, confidentiality and a litany of other problems.

Heaven or hell, the picture is pretty much the same: more petitions seeking redress, more special interests pursuing their agendas, more calls for accountability, more regulations, service codes and payment schemes; more regulatory bodies, public agencies, consultants, lawyers and courts to keep a lid on it all.

So, even in the unlikely event the role of the federal government is reduced, the role of other "command and control" agencies will more than pick up the slack. The net effect will be the continuing, relentless growth of the administered world. This isn't a theoretical argument, but an empirical hypothesis. It's a prediction on how things will play out based on history and the behavior of complex social systems. Smart money won't bet against it.

Meanwhile, it's not all doom and gloom. The intelligent application of technology to the delivery of health care, especially in information systems, can improve the experiences of both providers and consumers. Through public education and advocacy, we can help to insure that the regulatory, delivery and financing systems are responsive to concerns about access, quality and cost, although it will be impossible to satisfy everyone.

For starters, we might tone down the ideological rhetoric and stop pigeonholing positions and issues so we can more easily vilify and dismiss them. We need to wake up and look around. The world is hooking up at a breathtaking pace. This emerging web of new connections can be either chains to constrict freedom and choice or pathways to extend human possibilities.

Either way, the bureaucratization of the world is a done deal.