Bureaucracy in Healthcare and the impact of Labor unions

The usual American health politics story describes long seasons of stalemate punctuated by sudden moments of reform. Bold innovations are long contested, rarely won. The national health insurance debate, for example, is now in its ninth decade, the health care cost crisis in its third. However, a focus on health care bureaucracy yields a sharply different plot. A decade of quiet, incremental reforms has transformed our administrative politics, reshaping the organization, expectations, and distribution of authority in medical policy. There are at least three working models of authority in health care politics: professional, democratic, and bureaucratic (with an additional handful of largely theoretical alternatives, most notably the free market). Each locates accountability for health care in different hands.

The traditional view (which proved particularly resilient in the United States) placed authority over health policy squarely in the hands of the medical profession. Physicians, drawing on their expertise, operated as health care trustees. Legislators were solicitous, government bureaucrat's deferential, patients obedient, payers passive. The profession defeated the legislation it opposed, won the policies it supported, and guided the administration of existing health programs. Most nations eventually developed a second model, the social democratic one, in an effort to constrain the power of the medical profession.

The principles of democratic representation offered a counterweight to the authority of professional norms and knowledge. The state could set overall economic and social policy, then leave the professionals alone to practice within its frame. Although health care systems vary enormously from nation to nation, two key features characterize the social democratic model: Public officials, acting as monopsonists, bargain with professional groups over the health economy. And the economic bargains they strike (as well as the social rules they promulgate) are explicit, visible, and political. Like most representative institutions, this model claims legitimacy by offering citizens a public accounting for the choices made in their name. The analytic ideal is a public process in which officials act, explain, and are held to account (Thompson 1988; Pitkin 1967). Though political practice often falls short, this is the underlying basis of legitimacy for health policy across most of the industrialized world (Abel-Smith 1992; Hsiao 1992).

The rise of bureaucratic politics puts American health policy (and American public administration) in distinctly uncharted waters. We are diverging from both our own past politics and from international experience. More important, the new bureaucratic politics sets the institutional infrastructure for future change. After all, successful political reforms are rarely invented entirely new. Rather, they draw on existing programs, organizations, and institutional memories (Skocpol 1992; Skocpol and Finegold 1982). Contemporary programs-ranging from Medicare payment methodologies to corporate managed care plans-establish a framework for future changes. From a reform perspective, this is not a benign development; and from any angle, it is not a neutral one. The burgeoning American administrative apparatus can be expected to articulate and pursue its own interest. In any case, it will powerfully influence both the shape and the prospects of future health policies.

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