In The New Ruthless Economy, by Simon Head, there’s a great discussion of the expansion of bureaucracy in American healthcare. From loc 1728-1737:
Between 1968 and 1993, the number of managers and administrators tors in U.S. health care rose fourfold from 719,000 to 2,792,000, outstripping the growth in the number of physicians, which less than doubled from 430,000 to 761,000.4 The very high growth in of administrators ministrators changed the structure of employment in the health care industry dustry significantly. Between 1969 and 1993, the percentage of the total health care workforce employed in administration rose from 18 percent to 27 percent, while the percentage of physicians in the total health care workforce declined from 10.8 percent to 7.4 percent, and the total percentage of nurses fell from 40.6 percent to 36.3 percent. In U.S. hospitals, employment of administrators rose sharply, even as the number of patients declined.’ On an average day in 1968, U.S. hospitals employed 435,100 managers, administrators, and clerks to support the care of 1,378,000 inpatients. By 1990, the average daily number of patients had fallen by 39 percent to 853,000, but the number ber of administrators serving them had risen by 280 percent to 1,221,600. In 1968, there was one administrator for every three patients, tients, in 1990, 4.3 administrators for every three patients.
There’s a similar story that can be told about the expansion of bureaucracy in higher education. What drives this? In part I think it’s socio-technical innovation in auditing coupled with growth of an administrative class within organisations charged with utilising and intervening on the basis of this expanded capacity for audit. The constant drive to rationalise and reengineer organisations generates an ever expanding class of those driving the process who are insulated from the discipline they’re enforcing elsewhere.
This is compounded by counter-bureaucratic tendencies in other institutions. The particular kind of bureaucratic bloat digital capitalism gives rise to goes hand-in-hand with institutional isomorphism. The precise dynamics are specific to institutional spheres but the trend itself cuts across them. This is the example Simon Head cites:
The existence of this MCO bureaucracy has given rise to two counter-bureaucracies: one within doctors’ offices as physicians hire administrators to deal with MCO case managers, and another in hospitals pitals as managements hire administrators for the same purpose.
This is not the centralised bureaucracy of popular imagination but rather a bureaucratic build up within and across all organisations. I’d agree with the argument David Graeber made earlier this year that bureaucracy has been rendered peripheral in the popular and social scientific imaginations at precisely the time when it is becoming more prominent than ever.
Under such circumstances, I think the best hope for a leftist politics might be to reframe statism in terms of modernisation, overcoming the gross inefficiencies of the digital capitalist market place. Consider this example cited by Simon Head on loc 1711:
In February 1994 the New England Journal of Medicine published a research paper that sheds light on this last claim. The paper looks at variations in insurance coverage for a trial of an experimental treatment of breast cancer, autologous bone marrow transplant. Tucked away in the study was a remarkable statistic: The physicians running the trial had to deal with 187 insurance companies providing coverage for the 533 participating patients. Each company had its own database, expert panel, treatment guidelines, and bureaucracies of medical monitoring and control.