The transformation of health care delivery in the United States during the last twenty years is only one
of the latest developments in the long historical process that Max Weber called the "rationalization" of the Western world. According to Weber, over a period of many centuries, traditional, patrimonial techniques for legitimating authority have given way to "rational," bureaucratic ones. As part of that process, the authority of old-style, a “free”
professional such as private practice physicians is being replaced by the organizational authority of professional bureaucrats.
For thirty years, the mutually supportive policies of all these structural components
government, health care providers, insurance companies, and corporate employers have stimulated the growth of an increasingly massive, and expensive, health care industry. Without question, it is the American people who have paid for all this unexamined and uncoordinated spending, whether it was done by government or by private industry. The people have paid for it with money, since both the government and private insurance companies derive their funds from the masses of ordinary working people. They have paid for it with the worst morbidity and mortality statistics in the industrialized world, as millions of Americans have been excluded from a system they cannot afford to use. They have paid for it with the continuing hazards of poverty and industrial pollution, which is part of the price of maintaining a health care system that offers only "cures" while studiously ignoring the social causes of disease. And they have paid for it with the intense anxiety and aggravation that now accompanies many of our encounters with the health care delivery system. Although almost everyone is aware that "administrative costs" make up a huge percentage of what we pay for health care delivery, few analysts have attributed those costs to the bloated, self-reproducing, complex, and alienating surveillance systems that make up the most important part of what administrative systems do in America, whether they belong to government or to capitalist enterprises.
Several factors probably account for that failure. First, peer review itself is an extremely expensive process, both to implement and to maintain. During the last decade, it has come to be even more costly because, throughout the 1980s, it led to the emergence of whole new industries, along with expensive professional "experts" to staff them. In addition, the areas over which peer review must exercise surveillance have expanded continuously. At this point, rather than over utilizing health care services, we are over utilizing administrative surveillance. Second, hospital utilization has decreased only very slightly, while outpatient utilization has increased significantly.
Third, the control mechanisms were focused on the wrong problem in the first place. As a 1977 HEW status report to Congress pointed out, overutilization is only a secondary cause of health care inflation.
A fourth, and probably more important, explanation for the increase in health care costs may be that the commodification of health care services inevitably creates cost inflation that we all must pay for. Under this kind of commodification, creating and marketing the "sexiest" products to the most affluent "consumers" may inevitably result in a proliferation of products that are extremely profitable to drug and medical equipment manufacturers but that do nothing to improve our health statistics. But that is a topic for a different discussion.
Some contemporary analysts argue, from a great deal of data, that overutilization is no more the cause of our health care cost "crisis" today than it was in the 1970s; some even argue there is no cost crisis. Others seem to believe in the validity of part of the scenario that was established by industry in the 1970s, although not all of it. For example, Donald F. Beck and Jack Dempsey, noting that people continue to use medical services even when they are made to pay more for them through co-insurance and deductibles, believe that this behavior will change in the future. They believe that introducing "scientific rationality" into medical practice, rather than allowing physicians to continue practicing it as an "art," will cause physicians to lose even more status. This loss of status will lead to decreased utilization and, finally, less willingness by patients to pay for care. However, they do not believe scientific rationality will lead to lower health care costs. Health care will be even more expensive to deliver as a science than as an art; there will just be "far fewer mistakes." Thus, in their view, the transformation of health care is desirable not to cut costs but to improve the quality of care.
Today, as in the early 1970s, restructuring American health care is a topic that figures prominently in the news. If this revived political interest reflects a growing consensus that the existing system has reached its upper limit of complexity and costliness, at the same time that it excludes so many people as to make the situation politically risky, something actually may change. This may be the culmination of the political and ideological struggle to define our national health care values and goals that has been raging for more than twenty years. Or, if all the hoopla is simply the "sound and fury" that typically accompanies a political upset such as our last presidential election, it may signify nothing.